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Ye TW, Fu TW, Du CF, Yue RC, Jiang QT, Zhong ZH, Zhao Q, Zhang CW, Liu J, Liu JW, Luo ZY, Fan XM, Hong DF, Cheng J, Xiao ZQ. Comparison of percutaneous microwave/radiofrequency ablation liver partition and portal vein embolization versus transarterial chemoembolization and portal vein embolization for planned hepatectomy with insufficient future liver remnant. BMC Cancer 2024; 24:985. [PMID: 39123182 PMCID: PMC11312699 DOI: 10.1186/s12885-024-12666-z] [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: 01/29/2024] [Accepted: 07/21/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND In China, both percutaneous microwave/radiofrequency ablation liver partition plus portal vein embolization (PALPP) and transarterial chemoembolization (TACE) plus portal vein embolization (PVE) have been utilized in planned hepatectomy. However, there is a lack of comparative studies on the effectiveness of these two techniques for cases with insufficient future liver remnant (FLR). METHODS Patients were categorized into either the PALPP group or the TACE + PVE group. Clinical data, including FLR growth rate, complications, secondary resection rate, and overall survival rate, were compared and analyzed for both groups retrospectively. RESULTS Between December 2014 and October 2021, a total of 29 patients underwent TACE + PVE (n = 12) and PALPP (n = 17). In the TACE + PVE group, 7 patients successfully underwent two-stage hepatectomy, while in the PALPP group, 13 patients underwent the procedure (two-stage resection rate: 58.3% vs. 76.5%, P = 0.42). There were no significant differences in postoperative complications of one-stage procedures (11.8% vs. 8.3%, P > 0.05) and second-stage resection complication (0% vs. 46.2%, P = 0.05) between the TACE + PVE and PALPP groups. However, the PALPP group demonstrated a shorter time to FLR volume growth for second-stage resection (18.5 days vs. 66 days, P = 0.001) and KGR (58.5 ml/week vs. 7.7 ml/week, P = 0.001). CONCLUSIONS Compared with TACE + PVE, PALPP results in a more significant increase in FLR volume and a higher rate of two-stage resection without increasing postoperative complications.
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Affiliation(s)
- Tai-Wei Ye
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Tian-Wei Fu
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Cheng-Fei Du
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Ru-Chi Yue
- Three Gorges University, Yichang, Hubei, 443000, China
| | - Qi-Tao Jiang
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
| | - Zhi-Hang Zhong
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
| | - Qin Zhao
- Dalian Medical University, Dalian, Liaoning, 116000, China
| | - Cheng-Wu Zhang
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
| | - Jie Liu
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
| | - Jun-Wei Liu
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
| | - Zu-Yan Luo
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
| | - Xiao-Ming Fan
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China
| | - De-Fei Hong
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine(DeFei Hong), No.3 East Qingchun Road, Hangzhou, 310016, Zhejiang, China
| | - Jian Cheng
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China.
| | - Zun-Qiang Xiao
- General Surgery, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Cancer Center, Hangzhou, Zhejiang, 310014, China.
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Bilhim T, Böning G, Guiu B, Luz JH, Denys A. CIRSE Standards of Practice on Portal Vein Embolization and Double Vein Embolization/Liver Venous Deprivation. Cardiovasc Intervent Radiol 2024; 47:1025-1036. [PMID: 38884781 PMCID: PMC11303578 DOI: 10.1007/s00270-024-03743-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/20/2024] [Indexed: 06/18/2024]
Abstract
This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing liver regeneration therapies prior to major hepatectomies, including portal vein embolization, double vein embolization and liver venous deprivation. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It encompasses all clinical and technical details required to perform liver regeneration therapies, revising the indications, contra-indications, outcome measures assessed, technique and expected outcomes.
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Affiliation(s)
- Tiago Bilhim
- Interventional Radiology Unit, Curry Cabral Hospital, Unidade Local de Saúde São José; Centro Clínico Académico de Lisboa, SAMS Hospital, Lisbon, Portugal.
| | - Georg Böning
- Department of Radiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Boris Guiu
- Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | - José Hugo Luz
- Department of Interventional Radiology, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Alban Denys
- Department of Radiology and Interventional Radiology, Centre Hospitalier Universitaire Vaudois CHUV, University of Lausanne, Lausanne, Switzerland
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Lu YX, Zhao JP, Zhang WG. Is ALPPS still appropriate for large or locally advanced hepatocellular carcinoma in an era of targeted agents and immunotherapy? Updates Surg 2024; 76:899-910. [PMID: 38526694 DOI: 10.1007/s13304-024-01789-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/25/2024] [Indexed: 03/27/2024]
Abstract
Therapeutic options for large or locally advanced hepatocellular carcinoma (HCC) have limited efficacy. This study investigated the efficacy and safety of drug-eluting beads trans-arterial chemo-embolization (dTACE), portal vein embolization (PVE), tyrosine kinase inhibitor (TKI), and immune checkpoint inhibitors (ICI) compared to Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) for large or locally advanced HCC.Data regarding clinicopathological details, safety, and oncological outcomes were reviewed for the quadruple therapy (dTACE-PVE-TKI-ICI) and compared with ALPPS.From 2019 to 2020, 10 patients with large or locally advanced HCC underwent future remnant liver (FRL) modulation (dTACE-PVE-TKI-ICI: 5; ALPPS: 5). All five dTACE-PVE-TKI-ICI cases responded well, with patients #4 and #5 achieving complete tumor necrosis. The overall response rate (ORR) was 5/5. Patients #1-4 underwent hepatectomy, while #5 declined surgery due to complete tumor necrosis. Mean FRL volume increased by 75.3% (range 60.0%-89.4%) in 2-4 months, compared to 104.6% (range 51.3%-160.8%) in 21-37 days for ALPPS (P = 0.032). Major postoperative complications occurred in 1/5 ALPPS patients. Resection rates were 4/4 for quadruple therapy and 5/5 for ALPPS. 2-year progression free survival for dTACE-PVE-TKI-ICI and ALPPS were 5/5 and 3/5, respectively.Quadruple therapy is a feasible, effective strategy for enhancing resectability by downsizing tumors and inducing FRL hypertrophy, with manageable complications and improved long-term prognosis. In addition, it provokes the re-examination of the application of ALPPS in an era of molecular and immune treatments.
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Affiliation(s)
- Yuan-Xiang Lu
- Hepatic Surgery Center, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, China
| | - Jian-Ping Zhao
- Hepatic Surgery Center, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, China
| | - Wan-Guang Zhang
- Hepatic Surgery Center, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, China.
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Gang S, Ha S, Kwon H, Park J, Namgoong JM. Case report: Portal vein ligation: lessons from patients with PRETEXT III hepatoblastoma in restoring future liver remnant before major hepatectomy and literature review. Front Surg 2023; 10:1152901. [PMID: 37405062 PMCID: PMC10315569 DOI: 10.3389/fsurg.2023.1152901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/23/2023] [Indexed: 07/06/2023] Open
Abstract
Background We describe three cases involving three patients with PRETEXT III hepatoblastoma invading the hepatic hilum. After portal vein embolization, the patients underwent uncomplicated trisectionectomy. Methods Medical records between March 2016 and March 2021 were reviewed, and three patients were selected. A literature review of techniques for increasing future liver remnant in children diagnosed with hepatoblastoma was also conducted. Results All tumors involved the right lobe and hepatic hilum (PRETEXT III). After neoadjuvant chemotherapy, the tumor size decreased, but hilar involvement was unimproved. Right portal vein ligation (RPVL) was performed to increase the left lobe volume. Post-ligation, the remnant liver increased. Liver function was restored to normal levels within 5 days after the hepatectomy. All patients underwent two cycles of adjuvant chemotherapy without tumor recurrence. Conclusions RPVL can be safely performed before extended hepatic resection in children with a giant hepatoblastoma invading the hepatic hilum. The tumor was completely resected by securing a sufficient margin and increasing the residual liver volume with portal vein embolization. The patients recovered and underwent adjuvant chemotherapy without the deterioration of liver function.
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Wang Q, Wang A, Li Z, Sparrelid E, Brismar TB. Impact of sarcopenia on the future liver remnant growth after portal vein embolization and associating liver partition and portal vein ligation for staged hepatectomy in patients with liver cancer: A systematic review. Front Oncol 2022; 12:1064785. [PMID: 36505848 PMCID: PMC9730229 DOI: 10.3389/fonc.2022.1064785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/04/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose The impact of sarcopenia on the future liver remnant (FLR) growth after portal vein occlusion, including portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gained increasing interest. This systematic review aimed to explore whether sarcopenia was associated with insufficient FLR growth after PVE/ALPPS stage-1. Methods A systematic literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library up to 05 July 2022. Studies evaluating the influence of sarcopenia on FLR growth after PVE/ALPPS stage-1 in patients with liver cancer were included. A predefined table was used to extract information including the study and patient characteristics, sarcopenia measurement, FLR growth, post-treatment complications and post-hepatectomy liver failure, resection rate. Research quality was evaluated by the Newcastle-Ottawa Scale. Results Five studies consisting of 609 patients were included in this study, with a sample size ranging from 42 to 306 (median: 90) patients. Only one study was multicenter research. The incidence of sarcopenia differed from 40% to 67% (median: 63%). Skeletal muscle index based on pretreatment computed tomography was the commonly used parameter for sarcopenia evaluation. All included studies showed that sarcopenia impaired the FLR growth after PVE/ALPPS stage-1. However, the association between sarcopenia and post-treatment complications, post-hepatectomy liver failure, and resection rate remains unclear. All studies showed moderate-to-high quality. Conclusions Sarcopenia seems to be prevalent in patients undergoing PVE/ALPPS and may be a risk factor for impaired liver growth after PVE/ALPPS stage-1 according to currently limited evidence. Systematic review registration https://inplasy.com/, identifier INPLASY202280038.
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Affiliation(s)
- Qiang Wang
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Radiology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Anrong Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,Department of Interventional Therapy, People’s Hospital of Dianjiang County, Chongqing, China
| | - Zhen Li
- Department of Hepatobiliary Surgery, People’s Hospital of Dianjiang County, Chongqing, China,*Correspondence: Zhen Li,
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Torkel B. Brismar
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Radiology, Karolinska University Hospital Huddinge, Stockholm, Sweden
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Papamichail M, Pizanias M, Heaton ND, M P, M P, Nd H. Minimizing the risk of small-for-size syndrome after liver surgery. Hepatobiliary Pancreat Dis Int 2022; 21:113-133. [PMID: 34961675 DOI: 10.1016/j.hbpd.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS). DATA SOURCES This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS. RESULTS Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS. CONCLUSIONS With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.
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Affiliation(s)
- Michail Papamichail
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK.
| | - Michail Pizanias
- Department of General Surgery, Whittington Hospital, London N19 5NF, UK
| | - Nigel D Heaton
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Papamichail M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Pizanias M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Heaton Nd
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
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Maluf-Filho F, Meyer A, Martins PPM, Galvão FHF, D’Albuquerque LAC. Experimental model of portal hypertension and esophagogastric varices in minipigs: pressure and endoscopic pilot study. Acta Cir Bras 2022; 37:e370103. [PMID: 35262597 PMCID: PMC8901138 DOI: 10.1590/acb370103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/05/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Portal hypertension still represents an important health problem worldwide. In the search for knowledge regarding this syndrome, experimental studies with animal models have proven to be useful to point the direction to be taken in future randomized clinical trials. PURPOSE To validate the experimental model of portal hypertension and esophagogastric varices in a medium-sized animal. METHODS This study included five minipigs br1. Midline laparotomy with dissection of the portal vein and production of a calibrated stenosis of this vein was performed. Measurement of pressure in the portal venous and digestive endoscopic were performed before and five weeks after the production of a stenosis. RESULTS All animals were 8 months old, average weight of 17 ± 2.5 kg. The mean pressure of the portal vein immediately before the partial ligation of the portal vein was 8.9 + 1.6 mm Hg, with 26.6 + 5.4 mm Hg in the second measurement five weeks later (p < 0.05). No gastroesophageal varices or hypertensive portal gastropathy were seen at endoscopy procedures in our sample at any time in the study. CONCLUSION Portal vein ligation in minipigs has been validated in the production of portal hypertension, but not in the formation of esophageal varices.
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Affiliation(s)
| | - Alberto Meyer
- Liver and Abdominal Organs Transplantation Division, Brazil
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Hou F, Li X, Wang Y, Xiao X. MicroRNA-183 accelerates the proliferation of hepatocyte during liver regeneration through targeting programmed cell death protein 6. Genes Genomics 2022; 44:1017-1029. [PMID: 35190998 DOI: 10.1007/s13258-022-01223-2] [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: 08/06/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Liver regeneration is a highly orchestrated process concerning the modulation of various microRNAs (miRs). miR-183 was recently found to be involved in the process of liver regeneration, that miR-183 was remarkably up-regulated at 2-6 h after partial hepatectomy. OBJECTIVE This study was aimed to explore the mechanism of miR-183 in on liver regeneration. METHODS After partial hepatectomy (PH) or transfection, we measured the changes of miR-183 and programmed cell death protein 6 (PDCD6) levels in rats and the hepatocytes. The histopathology was observed with hematoxylin-eosin staining. The miR-183 mimic and inhibitor plasmids were intravenously injected into rats, and the liver weight/body weight ratio was calculated. The prediction of TargetScan and the validation of luciferase activity assay were employed to confirm the targeting relationship between miR-183 and PDCD6. The viability, apoptosis and cell cycle of transfected rat hepatocyte BRL-3A were determined via MTT and flow cytometry assays. RESULTS MiR-183 expression showed a contrary tendency with that of PDCD6 during liver regeneration. Enhanced miR-183 in rats could notably increase liver/body weight ratio, while its inhibition did conversely. Overexpressed PDCD6, a target of miR-183, repressed the viability and cell cycle in hepatocytes, whereas its silence led to contrary results. Overexpressed miR-183 in BRL-3A cells enhanced cell viability and promoted the cell cycle yet suppressed apoptosis, whereas its inhibition showed contrary results, which were offset by PDCD6. CONCLUSIONS Collectively, miR-183 promoted liver regeneration via targeting PDCD6.
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Affiliation(s)
- Fangxing Hou
- Queen Mary School, Nanchang University, Nanchang, Jiangxi, China
| | - Xing Li
- Oncology Chemotherapy Department, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, Hainan, China
| | - Yanfeng Wang
- Department of Pathology, Beidahuang Industry Group General Hospital, No. 235, hashuang Road, Nangang District, Harbin, 150000, China.
| | - Xiangzuo Xiao
- Department of Radiology, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China.
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Gutiérrez Sáenz de Santa María J, Herrero de la Parte B, Gutiérrez-Sánchez G, Ruiz Montesinos I, Iturrizaga Correcher S, Mar Medina C, García-Alonso I. Folinic Acid Potentiates the Liver Regeneration Process after Selective Portal Vein Ligation in Rats. Cancers (Basel) 2022; 14:cancers14020371. [PMID: 35053534 PMCID: PMC8773925 DOI: 10.3390/cancers14020371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/30/2021] [Accepted: 01/07/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary Fewer than 30% of patients with liver metastases are eligible for major liver resection, because liver remaining after such a surgery would be insufficient to cover the patient’s needs; this is called a low percentage of future liver remnant (FLR). Folinic acid (FA) has been shown to play a crucial role in cellular synthesis, regeneration, and nucleotide and amino acid biosynthesis. The aim of this piece of research was to evaluate the effect of FA as a potential hypertrophic hepatic enhancer agent after selective portal vein ligation (PVL) to ensure adequate FLR. We have confirmed in our rodent model that FA accelerates liver regeneration after PVL and enhances recovery of liver function. These findings may allow more patients to be eligible for liver resection without jeopardizing postoperative liver function. Abstract Liver resection remains the gold standard for hepatic metastases. The future liver remnant (FLR) and its functional status are two key points to consider before performing major liver resections, since patients with less than 25% FLR or a Child–Pugh B or C grade are not eligible for this procedure. Folinic acid (FA) is an essential agent in cell replication processes. Herein, we analyze the effect of FA as an enhancer of liver regeneration after selective portal vein ligation (PVL). Sixty-four male WAG/RijHsd rats were randomly distributed into eight groups: a control group and seven subjected to 50% PVL, by ligation of left portal branch. The treated animals received FA (2.5 m/kg), while the rest were given saline. After 36 h, 3 days or 7 days, liver tissue and blood samples were obtained. FA slightly but significantly increased FLR percentage (FLR%) on the 7th day (91.88 ± 0.61%) compared to control or saline-treated groups (86.72 ± 2.5 vs. 87 ± 3.33%; p < 0.01). The hepatocyte nuclear area was also increased both at 36 h and 7days with FA (61.55 ± 16.09 µm2, and 49.91 ± 15.38 µm2; p < 0.001). Finally, FA also improved liver function. In conclusion, FA has boosted liver regeneration assessed by FLR%, nuclear area size and restoration of liver function after PVL.
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Affiliation(s)
| | - Borja Herrero de la Parte
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Interventional Radiology Research Group, Biocruces Bizkaia Health Research Institute, ES48903 Barakaldo, Spain
- Correspondence: (B.H.d.l.P.); (I.R.M.)
| | - Gaizka Gutiérrez-Sánchez
- Department of Anesthesiology, Santa Creu i Sant Pau University Hospital, ES08025 Barcelona, Spain;
| | - Inmaculada Ruiz Montesinos
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Department of Gastrointestinal Surgery, Donostia University Hospital, ES20014 Donostia, Spain
- Correspondence: (B.H.d.l.P.); (I.R.M.)
| | - Sira Iturrizaga Correcher
- Department of Clinical Analyses, Galdakao-Usansolo Hospital, ES48960 Galdakao, Spain; (S.I.C.); (C.M.M.)
| | - Carmen Mar Medina
- Department of Clinical Analyses, Galdakao-Usansolo Hospital, ES48960 Galdakao, Spain; (S.I.C.); (C.M.M.)
| | - Ignacio García-Alonso
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Interventional Radiology Research Group, Biocruces Bizkaia Health Research Institute, ES48903 Barakaldo, Spain
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Kulkarni V. Anesthetic concerns in resection of liver: Case series. Anesth Essays Res 2022; 16:278-282. [DOI: 10.4103/aer.aer_91_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/18/2021] [Accepted: 07/13/2022] [Indexed: 11/04/2022] Open
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Dondorf F, Deeb AA, Bauschke A, Felgendreff P, Tautenhahn HM, Ardelt M, Settmacher U, Rauchfuss F. Ligation of the middle hepatic vein to increase hypertrophy induction during the ALPPS procedure. Langenbecks Arch Surg 2021; 406:1111-1118. [PMID: 33970336 PMCID: PMC8208903 DOI: 10.1007/s00423-021-02181-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Here, we analyse the technical modification of the ALPPS procedure, ligating the middle hepatic vein during the first step of the operation to enhance remnant liver hypertrophy. METHODS In 20 of 37 ALPPS procedures, the middle hepatic vein was ligated during the first step. Hypertrophy of the functional remnant liver volume was assessed in addition to postoperative courses. RESULTS Volumetric analysis showed a significant volume increase, especially for patients with colorectal metastases. Pre-existing liver parenchyma damage (odds ratio = 0.717, p = 0.017) and preoperative chemotherapy were found to be significant predictors (odds ratio = 0.803, p = 0.045) of higher morbidity and mortality. In addition, a survival benefit for maintenance of middle hepatic vein was shown. CONCLUSION This technical modification of the ALPPS procedure can accentuate future liver remnant volume hypertrophy. The higher morbidity and mortality observed are most likely associated with pre-existing parenchymal damage within this group.
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Affiliation(s)
- F Dondorf
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
| | - A Ali Deeb
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - A Bauschke
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - P Felgendreff
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
- Research Program "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena, Germany
| | - H M Tautenhahn
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
- Research Program "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena, Germany
| | - M Ardelt
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - U Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - F Rauchfuss
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
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Wildhaber BE, Terraz S. Portal vein embolization in children: As good as ALPPS. Ann Hepatobiliary Pancreat Surg 2021; 25:313-314. [PMID: 34053938 PMCID: PMC8180404 DOI: 10.14701/ahbps.2021.25.2.313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/02/2021] [Indexed: 01/11/2023] Open
Affiliation(s)
| | - Sylvain Terraz
- Unit of Interventional Radiology, Division of Radiology, Department of Diagnostics, University Hospitals of Geneva, Geneva, Switzerland
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Zhao J, Zhao W, Zhou H, Xu H, Yu L. Injection of CD86 + macrophages instead of liver partition for the acceleration of liver regeneration after portal vein ligation in rats. Arch Med Sci 2021; 17:843-847. [PMID: 34025858 PMCID: PMC8130466 DOI: 10.5114/aoms/133361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/15/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jinwei Zhao
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
| | - Weiyi Zhao
- Medical College of YanBian University, YanBian, China
| | - Hong Zhou
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
| | - Hongyue Xu
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
| | - Lu Yu
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
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Ašić A, Prguda-Mujić J, Salihefendić L, Bešić L, Ler D, Čeko I, Hadžović-Džuvo A, Jažić S, Konjhodžić R, Marjanović D. Serological testing for SARS-CoV-2 in Bosnia and Herzegovina: first report. Arch Med Sci 2021; 17:823-826. [PMID: 34025854 PMCID: PMC8130482 DOI: 10.5114/aoms/134143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/08/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Serological detection of SARS-CoV-2-specific immunoglobulins G (IgG) and M (IgM) antibodies is becoming increasingly important in the management of the COVID-19 pandemic. METHODS We report the first results of COVID-19 serological testing in Bosnia and Herzegovina on 2841 samples collected and analysed in 2 medical institutions in Sarajevo. Antibody detection was performed using commercially available kits. RESULTS In the first cohort, 43 IgM-positive/IgG-negative and 16 IgM-positive/IgG-positive individuals were detected, corresponding to 3.41% of participants having developed antibodies. In the second cohort, 4.28% participants were found to be IgM-negative/IgG-positive. CONCLUSIONS Our results suggest the need for population-wide serological surveying in Bosnia and Herzegovina.
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Affiliation(s)
- Adna Ašić
- Department of Genetics and Bioengineering, International Burch University, Sarajevo, Bosnia and Herzegovina
| | - Jasminka Prguda-Mujić
- Eurofarm Molecular Diagnostics Laboratory, Eurofarm Centre, Sarajevo, Bosnia and Herzegovina
| | - Lana Salihefendić
- Department of Genetics and Bioengineering, International Burch University, Sarajevo, Bosnia and Herzegovina
- Alea Genetic Centre, Health Institute Alea Dr. Kandić, Sarajevo, Bosnia and Herzegovina
| | - Larisa Bešić
- Department of Genetics and Bioengineering, International Burch University, Sarajevo, Bosnia and Herzegovina
| | - Daria Ler
- Eurofarm Molecular Diagnostics Laboratory, Eurofarm Centre, Sarajevo, Bosnia and Herzegovina
| | - Ivana Čeko
- Alea Genetic Centre, Health Institute Alea Dr. Kandić, Sarajevo, Bosnia and Herzegovina
| | - Almira Hadžović-Džuvo
- Department of Human Physiology, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
- Polyclinic and Daily Hospital Dr. Al-Tawil, Sarajevo, Bosnia and Herzegovina
| | - Sead Jažić
- Department of Microbiology Diagnostics, General Hospital Dr. Abdulah Nakaš, Sarajevo, Bosnia and Herzegovina
| | - Rijad Konjhodžić
- Alea Genetic Centre, Health Institute Alea Dr. Kandić, Sarajevo, Bosnia and Herzegovina
| | - Damir Marjanović
- Department of Genetics and Bioengineering, International Burch University, Sarajevo, Bosnia and Herzegovina
- Institute for Anthropological Research, University of Zagreb, Zagreb, Croatia
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Tsomaia K, Patarashvili L, Karumidze N, Bebiashvili I, Azmaipharashvili E, Modebadze I, Dzidziguri D, Sareli M, Gusev S, Kordzaia D. Liver structural transformation after partial hepatectomy and repeated partial hepatectomy in rats: A renewed view on liver regeneration. World J Gastroenterol 2020; 26:3899-3916. [PMID: 32774065 PMCID: PMC7385567 DOI: 10.3748/wjg.v26.i27.3899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/12/2020] [Accepted: 06/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The phenomenon of liver regeneration after partial hepatectomy (PH) is still a subject of considerable interest due to the increasing frequency of half liver transplantation on the one hand, and on the other hand, new surgical approaches which allow removal of massive space-occupying hepatic tumors, which earlier was considered as inoperable. Interestingly, the mechanisms of liver regeneration are extensively studied after PH but less attention is paid to the architectonics of the regenerated organ. Because of this, the question "How does the structure of regenerated liver differ from normal, regular liver?" has not been fully answered yet. Furthermore, almost without any attention is left the liver's structural transformation after repeated hepatectomy (of the re-regenereted liver). AIM To compare the architectonics of the lobules and circulatory bed of normal, re-generated and re-regenerated livers. METHODS The livers of 40 adult, male, albino Wistar rats were studied. 14 rats were subjected to PH - the 1st study group (SG1); 10 rats underwent repeated PH - the 2nd study group (SG2); 16 rats were subjected to sham operation - control group (CG); The livers were studied after 9 months from PH, and after 6 months from repeated PH. Cytological (Schiff reaction for the determination of DNA concen-tration), histological (H&E, Masson trichrome, CK8 Immunohistochemical marker, transparent slides after Indian Ink injection, ), morphometrical (hepatocytes areas, perimeters and ploidy) and Electron Microscopical (Scanning Electron Microscopy of corrosion casts) methods were used. RESULTS In the SG1 and SG2, the area of hepatocytes and their perimeter are increased compared to the CG (P < 0.05). However, the areas and perimeters of the hepatocytes of the SG1 and SG2 groups reveal a lesser difference. In regenerated (SG1) and re-regenerated (SG2) livers, the hepatocytes form the remodeled lobules, which size (300-1200 µm) exceeds the sizes of the lobules from CG (300-600 µm). The remodeled lobules (especially the "mega-lobules" with the sizes 1000-1200 µm) contain the transformed meshworks of the sinusoids, the part of which is dilated asymmetrically. This meshwork might have originated from the several portal venules (interlobular and/or inlet). The boundaries between the adjacent lobules (including mega-lobules) are widened and filled by connective tissue fibers, which gives the liver parenchyma a nodular look. In SG2 the unevenness of sinusoid diameters, as well as the boundaries between the lobules (including the mega-lobules) are more vividly expressed in comparison with SG1. The liver tissue of both SG1 and SG2 is featured by the slightly expressed ductular reaction. CONCLUSION Regenerated and re-regenerated livers in comparison with normal liver contain hypertrophied hepatocytes with increased ploidy which together with transformed sinusoidal and biliary meshworks form the remodeled lobulli.
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Affiliation(s)
- Keti Tsomaia
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0159, Georgia
| | - Leila Patarashvili
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0159, Georgia
| | - Nino Karumidze
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0159, Georgia
| | - Irakli Bebiashvili
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0159, Georgia
| | - Elza Azmaipharashvili
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0159, Georgia
| | - Irina Modebadze
- Faculty of Exact and Natural Sciences, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia
| | - Diana Dzidziguri
- Faculty of Exact and Natural Sciences, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia
| | - Marom Sareli
- Department of Surgical Oncology (Surgery C), Chaim Sheba Medical Center at HaShomer, Tel Aviv 52621, Israel
| | - Sergey Gusev
- Federal Research and Clinical Center of Physical-Chemical Medicine of Federal Medical Biological Agency, Moscow 119435, Russia
| | - Dimitri Kordzaia
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0159, Georgia
- Clinical Anatomy and Operative Surgery, Ivane Javakhishvili Tbilisi State University, Tbilisi 0159, Georgia
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Preoperative Portal Vein Embolization in Hepatic Surgery: A Review about the Embolic Materials and Their Effects on Liver Regeneration and Outcome. Radiol Res Pract 2020; 2020:9295852. [PMID: 32148959 PMCID: PMC7054797 DOI: 10.1155/2020/9295852] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 01/23/2020] [Indexed: 12/13/2022] Open
Abstract
Liver volume and function after hepatectomies are directly correlated to postoperative complications and mortality. Consequently contemporary liver surgery has focused on reaching an adequate future liver remnant so as to diminish postoperative morbidity and mortality. Portal vein embolization has evolved and is the standard of care as a liver regenerative strategy in many surgery departments worldwide before major liver resections. Different embolic materials have been used for portal vein embolization including gelfoam, ethanol, polyvinyl-alcohol particles, calibrated microspheres, central vascular plugs, coils, n-butyl-cyanoacrylate glue, fibrin glue, polidocanol-foam, alcoholic prolamin solution, and ethylene vinyl alcohol copolymer, as sole occluders or in varied combinations. While to date there has been no prospective controlled trial comparing the efficacy of different embolic materials in portal vein embolization, retrospective data insinuates that the use of n-butyl-cyanoacrylate and absolute ethanol produces higher contralateral liver hypertrophies. In this review, we evaluated publications up to August 2019 to assess the technical and regenerative results of portal vein embolization accomplished with different embolic materials. Special attention was given to specific aspects, advantages, and drawbacks of each embolic agent used for portal vein embolization, its liver regenerative performance, and its influence on patient outcome.
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Surgical resection of calcifying nested stromal-epithelial tumor in an adolescent female: A case report. Int J Surg Case Rep 2019; 66:1-3. [PMID: 31783327 PMCID: PMC6889362 DOI: 10.1016/j.ijscr.2019.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Calcifying nested stromal-epithelial tumor (CNSET) is an extremely rare, indolent tumor of the liver of uncertain cellular origin. With only 38 cases reported in the literature, pathogenesis and optimal therapeutic approach are not well characterized. Based on the available literature, the risk of recurrence is low with surgical resection with negative margins. PRESENTATION OF CASE In this case report, we describe an adolescent patient with CNSET who underwent right trisectionectomy. DISCUSSION In order to avoid posthepatectomy liver failure, special consideration must be given to the amount of residual liver parenchyma after resection when considering surgical approach. Single stage right trisectionectomy and two stage via associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) were both considered for surgical approach in this case in order to provide sufficient functional liver parenchyma remnant. CONCLUSION Given that obtaining negative margins is important in reducing the risk of recurrence, the method of surgical resection utilized is based on the amount of future functional residual hepatic parenchyma.
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Wu X, Huang Z, Lau WY, Li W, Lin P, Zhang L, Chen Y. Perioperative and long-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with well-preserved liver function and cirrhotic background: a propensity score matching study. Surg Endosc 2019; 33:206-215. [PMID: 29987565 DOI: 10.1007/s00464-018-6296-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although laparoscopic liver resection (LLR) has advanced into a safe and effective alternative to conventional open liver resection (OLR), it has not been widely accepted by surgeons. This article aimed to investigate the perioperative and long-term benefits of LLR versus OLR for hepatocellular carcinoma (HCC) in selected patients with well-preserved liver function and cirrhotic background. METHODS A retrospective study was conducted on 1085 patients with HCC who underwent liver resection at Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University from July 2010 to July 2015, and 346 patients with well-preserved liver function and cirrhotic background were selected. A 1:1 propensity score matching (PSM), which is the best option to overcome selection bias, was conducted to compare the surgical outcomes and long-term prognosis between LLR and OLR. After PSM, a logistic regression analysis was used to identify the predictive risk factors of posthepatectomy liver failure (PHLF). RESULTS By using PSM, the two groups were well balanced with 86 patients in each group. In the LLR group, only the median operation time was significantly longer than the OLR group, but the hospital stay, overall morbidity, and the incidence of PHLF were significantly decreased compared to OLR. There were no significant differences in the overall survival and disease-free survival rates between the two groups. On multivariate analysis, OLR was identified to be the only independent risk factor for PHLF. CONCLUSIONS In selected HCC patients with well-preserved liver function and cirrhotic background, LLR could be a better option compared to OLR.
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Affiliation(s)
- Xinqiang Wu
- Department of Hepato-biliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Zejian Huang
- Department of Hepato-biliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Wan Yee Lau
- Department of Hepato-biliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, People's Republic of China
| | - Wenda Li
- Department of Hepato-biliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Pai Lin
- Department of Hepato-biliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Lei Zhang
- Department of Hepato-biliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.
| | - Yajin Chen
- Department of Hepato-biliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.
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20
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Araújo TG, Oliveira AG, Franchi Teixeira AR. Low-Power Laser Irradiation (LPLI): A Clinical Point of View on a Promising Strategy to Improve Liver Regeneration. J Lasers Med Sci 2018; 9:223-227. [PMID: 31119014 DOI: 10.15171/jlms.2018.40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The capacity of the liver to regenerate is an important clinical issue after major hepatectomies and makes the difference between life and death in some cases of post-operative malfunction when the liver remnant is too small or has an impaired regenerative capacity. Several approaches have been tested to stimulate hepatic regeneration after post-operative hepatic failure syndrome; however, they have produced controversial results. A quick, simple, and harmless method that can be used intraoperatively and capable of promoting an increased regenerative capacity of the remaining liver would be very welcome. Thus, based on the data in the literature, we presented low-power laser irradiation (LPLI) as a quick, simple, and harmless method to improve liver regeneration after major hepatectomies. This article highlights the current evidence about the effects of LPLI on liver regeneration, and also suggests laser therapy as an important tool for regenerative stimulation in clinical practice.
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Affiliation(s)
- Tiago Gomes Araújo
- Department of Internal Medicine, State University of Campinas (UNICAMP), Campinas, SP, Brazil.,Department of Physiology and Pharmacology, Federal University of Pernambuco (UFPE), Recife, PE, Brazil
| | - Alexandre Gabarra Oliveira
- Department of Internal Medicine, State University of Campinas (UNICAMP), Campinas, SP, Brazil.,Institute of Biosciences Institute, São Paulo State University (UNESP), Rio Claro, SP, Brazil
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Compensatory hypertrophy of the liver after external beam radiotherapy for primary liver cancer. Strahlenther Onkol 2018; 194:1017-1029. [PMID: 30105451 DOI: 10.1007/s00066-018-1342-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 07/14/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE We investigated whether external beam radiotherapy (EBRT) could induce compensatory liver hypertrophy in liver cancers and assessed related clinical factors. METHODS A total of 82 consecutive patients receiving EBRT for hepatocellular carcinoma (n = 77) or cholangiocarcinoma (n = 5) from April 2012 to June 2014 were recruited and divided into two subgroups according to tumor location in the right or left lobe. The left lateral and right lobes were considered as unirradiated volumes accordingly. Total liver volume (TLV), nontumor liver volume (NLV), left and right lobe whole volume (LLWV and RLWV, respectively), volume of liver irradiated < 30 Gy (V< 30 Gy), Child-Pugh (CPS) score, future liver remnant (FLR) ratio, and percentage of FLR hypertrophy from baseline (%FLR) were assessed. RESULTS In the right lobe group, %FLR hypertrophy and LLWV increased significantly at all follow-ups (p < 0.001). %FLR hypertrophy steadily increased until the fourth follow-up. Multivariate analysis showed that the factor associated with maximum %FLR hypertrophy was tumor extent (upper or lower lobe vs. both lobes; p = 0.022). Post-RT treatments including transarterial chemoembolization or hepatic arterial infusion chemotherapy were associated with a CPS increase ≥ 2 (p = 0.002). Analysis of the RT only subgroup also showed a significant increase of %FLR until the fourth follow-up (p < 0.001). In the left lobe group, %FLR hypertrophy and RLWV showed no significant changes during follow-up. CONCLUSION Significant compensatory hypertrophy of the liver was observed, with a steady increase of %FLR hypertrophy until the fourth follow-up (median: 396 days). Locally advanced tumors extending across the upper and lower right lobe were a significant factor for compensating hypertrophy after EBRT.
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Sheng RF, Yang L, Jin KP, Wang HQ, Liu H, Ji Y, Fu CX, Zeng MS. Assessment of liver regeneration after associating liver partition and portal vein ligation for staged hepatectomy: a comparative study with portal vein ligation. HPB (Oxford) 2018; 20:305-312. [PMID: 29046260 DOI: 10.1016/j.hpb.2017.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/02/2017] [Accepted: 09/17/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND To investigate the diagnostic value of diffusion kurtosis imaging (DKI) and diffusion-weighted imaging (DWI) in assessing liver regeneration after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared with portal vein ligation (PVL). METHODS Thirty rats were divided into the ALPPS, PVL, and control groups. DKI and DWI were performed before and 7 days after surgery. Corrected apparent diffusion (D), kurtosis (K) and apparent diffusion coefficient (ADC) were calculated and compared, radiologic-pathologic correlations were evaluated. RESULTS The volume of the right median lobe increased significantly after ALPPS. There were larger cellular diameters after ALPPS and PVL (P = 0.0003). The proliferative indexes of Ki-67 and hepatocyte growth factor were higher after ALPPS (P = 0.0024/0.0433). D, K and ADC values differed between the groups (P = 0.021/0.0015/0.0008). A significant correlation existed between D and the hepatocyte size (r = -0.523), no correlations existed in ADC and K (P = 0.159/0.111). The proliferative indexes showed moderate negative correlations with ADC (r = -0.484/-0.537) and no correlations with D and K (P = 0.100-0.877). DISCUSSION Liver regeneration after ALPPS was effective and superior to PVL. DKI, especially the D map, may provide added value in evaluating the microstructure of liver regeneration after ALPPS, but this model alone may perform no better than the standard monoexponential model of DWI.
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Affiliation(s)
- Ruo-Fan Sheng
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Li Yang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Kai-Pu Jin
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - He-Qing Wang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Hao Liu
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Yuan Ji
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cai-Xia Fu
- MR Collaboration NEA, Siemens Ltd., China
| | - Meng-Su Zeng
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China.
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Tao W, Shi X, Wang G. Acute kidney injury following the first stage of the ALPPS procedure: A case report. Exp Ther Med 2018; 15:2990-2993. [PMID: 29599836 DOI: 10.3892/etm.2018.5789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/03/2017] [Indexed: 11/06/2022] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel approach for performing liver resection, and the number of clinical applications of this technique has rapidly increased within recent years. ALPPS is important in patients who have insufficient residual liver volume and cannot undergo radical hepatic resection. The most common postoperative complications of ALPPS include biliary fistula and infection. To date, postoperative acute kidney injury following ALPPS has not been reported. The current study reports the case of a 63-year-old patient with hepatitis B-induced cirrhosis who underwent the first stage of ALPPS without completion of the second step. The patient developed postoperative acute kidney injury following ALPPS. The present case study suggests that the use of ALPPS in patients at risk of chronic renal damage should be approached with caution in order to avoid postoperative acute kidney injury. Furthermore, improvements in surgical techniques and skills of the surgeons performing the procedure are required to reduce the surgery duration and improve patient outcomes.
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Affiliation(s)
- Weijie Tao
- Department of Hepatobiliary Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Xiaoju Shi
- Department of Hepatobiliary Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Guangyi Wang
- Department of Hepatobiliary Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Moris D, Ronnekleiv-Kelly S, Kostakis ID, Tsilimigras DI, Beal EW, Papalampros A, Dimitroulis D, Felekouras E, Pawlik TM. Operative Results and Oncologic Outcomes of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Versus Two-Stage Hepatectomy (TSH) in Patients with Unresectable Colorectal Liver Metastases: A Systematic Review and Meta-Analysis. World J Surg 2018; 42:806-815. [PMID: 28798996 DOI: 10.1007/s00268-017-4181-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently emerged as a treatment choice for patients with colorectal liver metastases (CLM) and inadequate future liver remnant (FLR). The aim of this study was to define the results of ALPPS compared with two-stage hepatectomy (TSH) for patients with CLM. MATERIALS AND METHODS A meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Identification of eligible studies was performed using three distinct databases through February 2017; Medline, ClinicalTrials.gov and Cochrane library-Cochrane Central Register of Controlled Trials using a syntax including medical subject headings terms "portal vein ligation," "PVE," "staged hepatectomy," "staged liver resection," "liver resection," "two-stage hepatectomy," "TSH," "in situ liver transection with portal vein ligation," "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". RESULTS Among the 634 records identified, 9 studies comparing ALPPS with TSH met the inclusion criteria. These studies included 657 patients with unresectable CLM (ALPPS, n = 186 vs TSH, n = 471). There was no difference in final postoperative FLR between ALPPS versus TSH (mean difference: 31.72, 95% CI: -27.33 to 90.77, p = 0.29). The kinetic growth rate was faster with the ALPPS versus TSH (mean difference 19.07 ml/day, 95% CI 8.12-30.02, p = 0.0006). TSH had a lower overall and major morbidity versus ALPPS (overall morbidity: RR: 1.39, 95% CI: 1.07-1.8, p = 0.01; I 2: 58%, p = 0.01; major morbidity: RR: 1.57, 95% CI: 1.18-2.08, p = 0.002; I 2: 0%, p = 0.44). Overall survival was comparable following ALPPS versus TSH. CONCLUSION While ALPPS may be a suitable approach for patients, the higher morbidity and mortality should be considered when determining the operative approach for patients with extensive CLM.
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Affiliation(s)
- Dimitrios Moris
- Department of Surgery, Division of Surgical Oncology, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Sean Ronnekleiv-Kelly
- Department of Surgery, Division of Surgical Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ioannis D Kostakis
- 2nd Department of Propedeutic Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Diamantis I Tsilimigras
- 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eliza W Beal
- Department of Surgery, Division of Surgical Oncology, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Alexandros Papalampros
- 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- 2nd Department of Propedeutic Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Felekouras
- 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Giménez ME, Houghton EJ, Davrieux CF, Serra E, Pessaux P, Palermo M, Acquafresca PA, Finger C, Dallemagne B, Marescaux J. PERCUTANEOUS RADIOFREQUENCY ASSISTED LIVER PARTITION WITH PORTAL VEIN EMBOLIZATION FOR STAGED HEPATECTOMY (PRALPPS). ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2018; 31:e1346. [PMID: 29513807 PMCID: PMC5863995 DOI: 10.1590/0102-672020180001e1346] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/08/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND When a major hepatic resection is necessary, sometimes the future liver remnant is not enough to maintain sufficient liver function and patients are more likely to develop liver failure after surgery. AIM To test the hypothesis that performing a percutaneous radiofrecuency liver partition plus percutaneous portal vein embolization (PRALPPS) for stage hepatectomy in pigs is feasible. METHODS Four pigs (Sus scrofa domesticus) both sexes with weights between 25 to 35 kg underwent percutaneous portal vein embolization with coils of the left portal vein. By contrasted CT, the difference between the liver parenchyma corresponding to the embolized zone and the normal one was identified. Immediately, using the fusion of images between ultrasound and CT as a guide, radiofrequency needles were placed percutaneouslyand then ablated until the liver partition was complete. Finally, hepatectomy was completed with a laparoscopic approach. RESULTS All animals have survived the procedures, with no reported complications. The successful portal embolization process was confirmed both by portography and CT. In the macroscopic analysis of the pieces, the depth of the ablation was analyzed. The hepatic hilum was respected. On the other hand, the correct position of the embolization material on the left portal vein could be also observed. CONCLUSION "Percutaneous radiofrequency assisted liver partition with portal vein embolization" (PRALLPS) is a feasible procedure.
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Affiliation(s)
- Mariano E Giménez
- University of Buenos Aires, Buenos Aires, Argentina
- Docencia Asistencia Investigación en Cirugía Invasiva Mínima (DAICIM) Foundation, Buenos Aires, Argentina
- Institut Hospitalo-Universitaire (IHU), Strasbourg, France
- Institut de Recherche contre les Cancers de l´Appareil Digestif (IRCAD), Strasbourg, France
| | - Eduardo J Houghton
- University of Buenos Aires, Buenos Aires, Argentina
- Docencia Asistencia Investigación en Cirugía Invasiva Mínima (DAICIM) Foundation, Buenos Aires, Argentina
- Hospital Bernardino Rivadavia, Buenos Aires, Argentina
| | - C Federico Davrieux
- Docencia Asistencia Investigación en Cirugía Invasiva Mínima (DAICIM) Foundation, Buenos Aires, Argentina
- Institut Hospitalo-Universitaire (IHU), Strasbourg, France
- Institut de Recherche contre les Cancers de l´Appareil Digestif (IRCAD), Strasbourg, France
| | - Edgardo Serra
- Docencia Asistencia Investigación en Cirugía Invasiva Mínima (DAICIM) Foundation, Buenos Aires, Argentina
- Centro Integral de Endocrinología y Nutrición (CIEN) Center, Argentina
| | - Patrick Pessaux
- Institut Hospitalo-Universitaire (IHU), Strasbourg, France
- Institut de Recherche contre les Cancers de l´Appareil Digestif (IRCAD), Strasbourg, France
- Novel Hôpital Civil, University of Strasbourg, Strasbourg, France
| | - Mariano Palermo
- University of Buenos Aires, Buenos Aires, Argentina
- Docencia Asistencia Investigación en Cirugía Invasiva Mínima (DAICIM) Foundation, Buenos Aires, Argentina
| | - Pablo A Acquafresca
- Docencia Asistencia Investigación en Cirugía Invasiva Mínima (DAICIM) Foundation, Buenos Aires, Argentina
| | - Caetano Finger
- Docencia Asistencia Investigación en Cirugía Invasiva Mínima (DAICIM) Foundation, Buenos Aires, Argentina
- Hospital Juan A. Fernández, Buenos Aires, Argentina
| | - Bernard Dallemagne
- Institut Hospitalo-Universitaire (IHU), Strasbourg, France
- Institut de Recherche contre les Cancers de l´Appareil Digestif (IRCAD), Strasbourg, France
- Novel Hôpital Civil, University of Strasbourg, Strasbourg, France
| | - Jacques Marescaux
- Institut Hospitalo-Universitaire (IHU), Strasbourg, France
- Institut de Recherche contre les Cancers de l´Appareil Digestif (IRCAD), Strasbourg, France
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First Ever Robotic Stage One ALPPS Procedure in India: for Colorectal Liver Metastases. Indian J Surg 2017; 80:269-271. [PMID: 29973758 DOI: 10.1007/s12262-017-1713-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 12/08/2017] [Indexed: 02/08/2023] Open
Abstract
Twenty five percent of total liver volume (TLV) is considered as the ideal functional liver remnant (FLR) in major liver resections. In patients with macro-vesicular steatosis, early cirrhosis, and post-neoadjuvant chemotherapy (NACT), hepatocellular injury is common. In such instances, up to 40% of FLR may be required. So in cases of marginal FLR, pre-operative portal vein (PV) embolization or two-stage hepatectomy with PV occlusion is used. Both of which take up to 14 weeks between stages and 30% of patients fail to reach the second resection either due to inadequate FLR growth or disease progression. Associated liver partition and portal vein ligation (ALPPS) procedure has become the gold standard for those cases. A 57-year-old male presented with rectosigmoid growth + multiple right liver and segment 4B metastases. Post-NACT MRI showed interval progression of lesions. Preoperative CT (computed tomography) volumetric scan showed a FLR/TLV (future liver remnant/total liver volume) of 22%. Since patient received 10 cycles of NACT, ALPPS procedure was planned ahead of direct liver resection. Robotic ALPPS stage 1 sparing left lateral segment and 4A + anterior resection was done. We transected the parenchyma between the FLR and the diseased part of the liver with concomitant right portal vein ligation done robotically. CT abdomen done on POD7 showed hypertrophied left lateral segment. Second stage was performed on the eighth post-operative day with FLR/TLV increasing to 37%. Robotic ALPPS procedure for stage one is a safe and feasible technique in experienced centers with advanced robotic skills.
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Zhou Z, Xu M, Lin N, Pan C, Zhou B, Zhong Y, Xu R. Associating liver partition and portal vein ligation for staged hepatectomy versus conventional two-stage hepatectomy: a systematic review and meta-analysis. World J Surg Oncol 2017; 15:227. [PMID: 29258518 PMCID: PMC5738171 DOI: 10.1186/s12957-017-1295-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/08/2017] [Indexed: 02/08/2023] Open
Abstract
Background It is generally accepted that an insufficient future liver remnant is a major limitation of large-scale hepatectomy for patients with primary hepatocellular carcinoma. Conventional two-stage hepatectomy (TSH) is commonly considered to accelerate future liver regeneration despite its low regeneration rate. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), which is characterized by a rapid regeneration, has brought new opportunities. Methods Relevant studies were identified by searching the selected databases up to September 2017. Then, a meta-analysis of regeneration efficiency, complication rate, R0 resection ratio, and short-term outcomes was performed. Results Ten studies, comprising 719 patients, were included. The overall analysis showed that ALPPS was associated with a larger hyperplastic volume and a shorter time interval (P < 0.00001) than TSH. ALPPS also exhibited a higher completion rate for second-stage operations (odds ratio, OR 9.50; P < 0.0001) and a slightly higher rate of R0 resection (OR 1.90; P = 0.11). Interestingly, there was no significant difference in 90-day mortality between the two treatments (OR 1.44; P = 0.35). Conclusions These results indicate that compared with TSH, ALPPS possesses a stronger regenerative ability and better facilitates second-stage operations. However, the safety, patient outcomes, and patient selection for ALPPS require further study. Electronic supplementary material The online version of this article (10.1186/s12957-017-1295-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zheng Zhou
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Mingxing Xu
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Nan Lin
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Chuzhi Pan
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Boxuan Zhou
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Yuesi Zhong
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Ruiyun Xu
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China.
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Maulat C, Philis A, Charriere B, Mokrane FZ, Guimbaud R, Otal P, Suc B, Muscari F. Rescue associating liver partition and portal vein ligation for staged hepatectomy after portal embolization: Our experience and literature review. World J Clin Oncol 2017; 8:351-359. [PMID: 28848702 PMCID: PMC5554879 DOI: 10.5306/wjco.v8.i4.351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 06/05/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), after failure of previous portal embolization. We also performed a literature review.
METHODS Between January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization (PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps (ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened during the interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification.
RESULTS From January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc (221-380), 450 cc (372-506), and 660 cc (575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4% (0.3-0.5), 0.6% (0.5-0.8), and 1% (0.8-1.2). Median volume growth of FLR was 69% (18-92) after PVE, and 45% (36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc (254-513), leading to an increase of +149% (68-199). After ALPPS-2, 4 patients had stage I-II complications. Three patients had more severe complications (one stage III, one stage IV and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure.
CONCLUSION Rescue ALPPS may be an alternative after unsuccessful PVE and could allow previously unresectable patients to reach surgery. Biliary drainage seems to reduce biliary complications.
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Sheng RF, Wang HQ, Jin KP, Yang L, Liu H, Ji Y, Fu CX, Zeng MS. Histogram analyses of diffusion kurtosis indices and apparent diffusion coefficient in assessing liver regeneration after ALPPS and a comparative study with portal vein ligation. J Magn Reson Imaging 2017. [PMID: 28640476 DOI: 10.1002/jmri.25793] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Ruo-fan Sheng
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - He-qing Wang
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - Kai-pu Jin
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - Li Yang
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - Hao Liu
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - Yuan Ji
- Department of Pathology, Zhongshan Hospital; Fudan University; Shanghai P.R. China
| | | | - Meng-su Zeng
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
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Zerial M, Lorenzin D, Risaliti A, Zuiani C, Girometti R. Abdominal cross-sectional imaging of the associating liver partition and portal vein ligation for staged hepatectomy procedure. World J Hepatol 2017; 9:733-745. [PMID: 28652892 PMCID: PMC5468342 DOI: 10.4254/wjh.v9.i16.733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/22/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a recently introduced technique aimed to perform two-stage hepatectomy in patients with a variety of primary or secondary neoplastic lesions. ALPSS is based on a preliminary liver resection associated with ligation of the portal branch directed to the diseased hemiliver (DH), followed by hepatectomy after an interval of time in which the future liver remnant (FLR) hypertrophied adequately (partly because of preserved arterialization of the DH). Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) play a pivotal role in patients’ selection and FLR assessment before and after the procedure, as well as in monitoring early and late complications, as we aim to review in this paper. Moreover, we illustrate main abdominal MDCT and MRI findings related to ALPPS.
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Zhai B, Jin X, Wang R, Fang T, Qu J, Wang Y, Liu M, Xu L. Applying negative pressure wound therapy in associating liver partition and portal vein ligation for staged hepatectomy: A case report. Exp Ther Med 2017; 14:642-646. [PMID: 28672979 PMCID: PMC5488412 DOI: 10.3892/etm.2017.4566] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 03/03/2017] [Indexed: 12/30/2022] Open
Abstract
Staged hepatectomy, particularly associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a recently developed advanced surgery for resecting liver tumors. However, large wound surfaces, incomplete drainage and high rates of mortality are vital limitations of ALPPS. The present case study describes a patient with liver cancer who underwent ALPPS surgery combined with negative pressure wound therapy. A 46-year-old male patient was hospitalized due to right upper abdominal pain. Computed tomography and magnetic resonance cholangiopancreatography scan results indicated gallbladder cancer, accompanied by multiple liver metastases. Resection of the right trisegment and partial resection of metastatic nodules in the left outer lobe were performed. Vacuum sealing drainage was pre-implanted at liver cross-sections with drainage tubes to drain the bile. The patient exhibited improved wound healing compared with conventional ALPPS.
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Affiliation(s)
- Bo Zhai
- Department of General Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Xin Jin
- Department of General Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Rui Wang
- Department of Gastroenterology, Heilongjiang Provincial Hospital, Harbin, Heilongjiang 150036, P.R. China
| | - Taishi Fang
- Department of General Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Jing Qu
- Department of Orthopedics, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Ying Wang
- Department of Anesthesiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Ming Liu
- Department of General Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Lishan Xu
- Department of General Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
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Sanei B, Sheikhbahaei S, Sanei MH, Bahreini A, Jafari HR. Associating liver partition and portal vein ligation for staged hepatectomy: A surgical technique for liver resections. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 22:52. [PMID: 28567071 PMCID: PMC5426088 DOI: 10.4103/jrms.jrms_829_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/02/2017] [Accepted: 01/29/2017] [Indexed: 12/27/2022]
Abstract
Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel surgical technique liver resection in traditionally nonresectable primary intrahepatic tumors or colorectal liver metastases. Materials and Methods: From June 2013 to March 2014, patients with primary tumor of liver or colorectal tumors with liver metastasis were selected to evaluate whether they met the initial criteria for ALPPS procedure. Results: Nine patients enrolled in the study with primary diagnoses of colon and rectosigmoid cancer, carcinoid tumor, gastrointestinal stromal tumor of small intestine, hepatocellular carcinoma, and pancreatic neuroendocrine tumor (PNET). Four candidates excluded from the study prior or during the first step operation due to fatty liver, hepatic fibrosis, peritoneal seeding, and multiple small intestine metastases. Five patients underwent two stages of ALPPS with the interval of about 1 week. Liver hypertrophy was 100% among our candidates after the initial step. One postoperative death happened because of massive pulmonary thromboembolism Recurrence of liver metastasis was seen in one patient. Hepatic failure Class B and A were observed in two patients which did not progress during follow-up period. One patient developed an enterocutaneous fistula. Discussion: We recommend to use 2 organ bags, one for wrapping right lobe and the other one for covering visceral organs and also do liver biopsy in suspicious cases of damaged liver parenchyma and laparoscopic exploration of abdomen for seeding and multiple metastases prior to laparotomy. Conclusion: As the procedure has not been well established and verified by oncologists yet, further studies are required to define the exact indications of ALPPS.
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Affiliation(s)
- Behnam Sanei
- Department of Liver Transplant and Hepatobiliary and Pancreatic Surgery, Isfahan, Iran.,Department of General Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saba Sheikhbahaei
- Acquired Immunodeficiency Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Amin Bahreini
- Department of Liver Transplant and Hepatobiliary and Pancreatic Surgery, Ahvaz, Iran.,Department of General Surgery, Jundishapour University of Medical Sciences, Ahvaz, Iran
| | - Hamid Reza Jafari
- Department of General Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
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Gaba RC, Bui JT, Emmadi R, Lakhoo J. Ablative Liver Partition and Portal Vein Embolization: Proof-of-Concept Testing in a Rabbit Model. J Vasc Interv Radiol 2017; 28:906-912.e1. [PMID: 28292634 DOI: 10.1016/j.jvir.2017.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 01/25/2017] [Accepted: 02/07/2017] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To test the hypothesis that a modified approach to portal vein embolization (PVE)-termed ablative liver partition (ALP) and PVE (ALP-PVE)-is feasible and results in greater future liver remnant (FLR) growth compared with PVE alone in a rabbit model. MATERIALS AND METHODS Eighteen rabbits (median weight, 2.7 kg) underwent PVE (n = 9) or ALP-PVE (n = 9). PVE to cranial liver lobes was performed with 100-300-μm microspheres and metallic coils; the caudal lobe was spared as the FLR. In the ALP-PVE cohort, a liver partition between cranial and caudal lobes was created by using microwave ablation (40 W, 1 min). Animals were euthanized and livers were harvested on postprocedure day 7. Caudal and cranial liver lobes were weighed after 4 weeks of oven drying. Ki-67 immunohistochemistry was used to quantify liver mitotic index. ALP-PVE feasibility was determined based on procedure technical success. Standardized FLR (sFLR; ie, FLR divided by whole liver weight) and mitotic index were compared between PVE and ALP-PVE groups by two-tailed independent-samples Mann-Whitney U test. RESULTS One PVE-group rabbit died during anesthesia induction and was excluded from technical success calculation. Eight of 8 (100%) and 8 of 9 rabbits (89%) underwent technically successful PVE and ALP-PVE, respectively. There was no difference in sex or weight distribution between groups. sFLR (0.32 vs 0.29; P = .022) and mitotic index (17.5% vs 6.2%; P = .051) were higher in ALP-PVE vs PVE caudal lobes when the first "learning-curve" case from each group was excluded. CONCLUSIONS ALP-PVE is feasible and may stimulate greater FLR growth compared with PVE in a rabbit model.
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Affiliation(s)
- Ron C Gaba
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612.
| | - James T Bui
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - Rajyasree Emmadi
- Department of Pathology, University of Illinois Hospital & Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - Janesh Lakhoo
- College of Medicine, University of Illinois Hospital & Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
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Olthof SC, Othman A, Clasen S, Schraml C, Nikolaou K, Bongers M. Imaging of Cholangiocarcinoma. Visc Med 2016; 32:402-410. [PMID: 28229074 DOI: 10.1159/000453009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cholangiocarcinoma (CC) is the second most common primary hepatobiliary tumour, and it is increasing in incidence. Imaging characteristics, behaviour, and therapeutic strategies in CC differ significantly, depending on the morphology and location of the tumour. In cross-sectional imaging, CCs can be classified according to the growth pattern (mass-forming, periductal infiltrating, intraductal) and the location (intrahepatic, perihilar, extrahepatic/distal). The prognosis of CC is unfavourable and surgical resection is the only curative treatment option; thus, early diagnosis (also in recurrent disease) and accurate staging including the evaluation of lymph node involvement and vascular infiltration is crucial. However, the diagnostic evaluation of CC is challenging due to the heterogeneous nature of the tumour. Diagnostic modalities used in the imaging of CC include transabdominal ultrasound, endosonography, computed tomography, magnetic resonance imaging with cholangiopancreatography, and hybrid imaging such as positron emission tomography/computed tomography. In this review, the potential of cross-sectional imaging modalities in primary staging, treatment monitoring, and detection of recurrent disease will be discussed.
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Affiliation(s)
- Susann-Cathrin Olthof
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Ahmed Othman
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Stephan Clasen
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Christina Schraml
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Malte Bongers
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
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Chen XB, Zheng XB, Cai ZX, Lin XJ, Xu MQ. MicroRNA-203 promotes liver regeneration after partial hepatectomy in cirrhotic rats. J Surg Res 2016; 211:53-63. [PMID: 28501131 DOI: 10.1016/j.jss.2016.11.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 11/06/2016] [Accepted: 11/23/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver resection or partial hepatectomy (PH) is still the most commonly used therapeutic option for hepatocellular carcinoma (HCC) at present. However, the impaired regenerative ability induced by the accompanied liver cirrhosis is an important risk factor of posthepatectomy liver failure, and posthepatectomy liver failure is a feared complication that accounts for up to 75% of mortality after extensive liver resection. MicroRNA(miR)-203 is a tumor suppressor of HCC and may act as a positive intermediary in A20-enhanced interleukin (IL-6)/signal transducer and activator of transcription 3 (STAT3) pro-proliferative signals, which may promote liver regeneration after PH. However, its direct pro-proliferative effect on cirrhotic liver after hepatectomy is unknown. MATERIALS AND METHODS Liver cirrhosis was induced by intraperitoneal injection of 50% CCl4-olive oil solution in adult male Wistar rat. Rats with liver cirrhosis received portal vein injection of physiological saline, miR-203 lentivirus, or control empty lentivirus, and then 70% PH was performed under ether anesthesia 7 d later. Liver samples were harvested at 0, 24, 36, and 72 h after 70% PH. Hepatic expressions of cyclin D1 and Ki67 were checked to evaluate the liver regenerative ability. Hepatic expressions of IL-6, suppressor of cytokine signaling 3 (SOCS3), and phospho-STAT3 were also tested to clarify the mechanisms of miR-203 in liver regeneration. RESULTS The regeneration of miR-203 overexpression cirrhotic liver after 70% PH was enhanced and peaked at 24 and 36 h after 70% PH. The cyclin D1-positive liver cells/high-power field (HPF) in miR-203 overexpression liver markedly increased at 24 and 36 h after 70% PH compared with 0-h samples. When comparing with the control groups, cyclin D1-positive liver cells/HPF in miR-203 overexpression liver were also significantly increased at 24 and 36 h after 70% PH. A similar result of the Ki67-positive liver cells/HPF was achieved at 36 h after 70% PH. The hepatic expression of IL-6 showed a rising tendency after 70% PH, and the levels of IL-6 are significantly higher in miR-203 overexpression livers. Hepatic expression of SOCS3 was negatively expressed with hepatic miR-203 expression level, and the reduced expression of SOCS3 facilitated the phosphorylation of STAT3. CONCLUSIONS By targeting SOCS3 and then enhancing proliferating IL-6/STAT3 signaling pathway, hepatic overexpression of miR-203 can facilitate the initiation of liver regeneration and enhance the potency of liver regeneration after 70% PH in cirrhotic rat. Together with the tumor suppressive effect on HCC, miR-203 would be an ideal candidate for promoting liver regeneration in HCC patients undergoing liver resection without the risk of tumorigenesis or cancer recurrence.
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Affiliation(s)
- Xiao-Bo Chen
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiao-Bo Zheng
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhen-Xing Cai
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xian-Jian Lin
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ming-Qing Xu
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastasis: the radiologist's perspective. Abdom Radiol (NY) 2016; 41:2150-2160. [PMID: 27377899 DOI: 10.1007/s00261-016-0832-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Hepatic resection is the only potentially curative treatment for patients with colorectal liver metastasis (CRLM). Many multidisciplinary approaches, including the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, have been proposed to increase the resectability rate in these patients. ALPPS is the most recently described staged liver resection technique, representing an advantageous strategy to induce a rapid and marked increase in the future liver remnant (FLR) volume. The aim of this article is to describe the radiological evaluation of this procedure and its variation. METHODS This retrospective study included 9 patients with CRLM who underwent the ALPPS procedure. Abdominal imaging studies were reviewed, with an emphasis on a rational radiological approach. The number of liver metastases, the FLR volume (pre- and postportal vein ligation), anatomical variations, potential pitfalls related to disease progression, and postoperative complications were evaluated. RESULTS The types of hepatic resection included 4 classical ALPPS cases, 3 right ALPPS variations, and 2 left ALPPS variations. The mean FLR volume calculated in the initial evaluation was 453 mL (213-790 mL). Following the first surgery, the mean FLR volume increased to 634 mL (410-957 mL), which indicated a mean volume increase of 181.1 mL (95% CI 149.7-212.5 mL; p < 0.001) and a mean absolute volume increase of 48% (19%-88%). CONCLUSION The ALPPS procedure is an emerging form of two-stage hepatectomy. In this context, radiologists should provide crucial preoperative and perioperative information that may change surgical planning and contribute to an improvement in the oncologic outcome.
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Moris D, Vernadakis S, Papalampros A, Vailas M, Dimitrokallis N, Petrou A, Dimitroulis D. Mechanistic insights of rapid liver regeneration after associating liver partition and portal vein ligation for stage hepatectomy. World J Gastroenterol 2016; 22:7613-7624. [PMID: 27672282 PMCID: PMC5011675 DOI: 10.3748/wjg.v22.i33.7613] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 06/09/2016] [Accepted: 07/06/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To highlight the potential mechanisms of regeneration in the Associating Liver Partition and Portal vein ligation for Stage hepatectomy models (clinical and experimental) that could unlock the myth behind the extraordinary capability of the liver for regeneration, which would help in designing new therapeutic options for the regenerative drive in difficult setup, such as chronic liver diseases. Associating Liver Partition and Portal vein ligation for Stage hepatectomy has been recently advocated to induce rapid future liver remnant hypertrophy that significantly shortens the time for the second stage hepatectomy. The introduction of Associating Liver Partition and Portal vein ligation for Stage hepatectomy in the surgical armamentarium of therapeutic tools for liver surgeons represented a real breakthrough in the history of liver surgery. METHODS A comprehensive literature review of Associating Liver Partition and Portal vein ligation for Stage hepatectomy and its utility in liver regeneration is performed. RESULTS Liver regeneration after Associating Liver Partition and Portal vein ligation for Stage hepatectomy is a combination of portal flow changes and parenchymal transection that generate a systematic response inducing hepatocyte proliferation and remodeling. CONCLUSION Associating Liver Partition and Portal vein ligation for Stage hepatectomy represents a real breakthrough in the history of liver surgery because it offers rapid liver regeneration potential that facilitate resection of liver tumors that were previously though unresectable. The jury is still out though in terms of safety, efficacy and oncological outcomes. As far as Associating Liver Partition and Portal vein ligation for Stage hepatectomy -induced liver regeneration is concerned, further research on the field should focus on the role of non-parenchymal cells in liver regeneration as well as on the effect of Associating Liver Partition and Portal vein ligation for Stage hepatectomy in liver regeneration in the setup of parenchymal liver disease.
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Papamichail M, Pizanias M, Yip V, Prassas E, Prachalias A, Quaglia A, Peddu P, Heaton N, Srinivasan P. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure for hepatocellular carcinoma with chronic liver disease: a case report and review of literature. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:75-80. [PMID: 27212995 PMCID: PMC4874049 DOI: 10.14701/kjhbps.2016.20.2.75] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/10/2016] [Accepted: 02/18/2016] [Indexed: 12/29/2022]
Abstract
The incidence of complications after liver resection is closely related to functional future liver remnant (FLR). The standard approach to augment FLR is surgical or radiological occlusion of the artery or portal vein on the tumor side. Associated liver partition and portal vein ligation for staged hepatectomy (ALLPS) has been introduced as an alternative method to augment FLR. It offers rapid and effective hypertrophy for resecting liver metastases. However, data regarding its application in patients with hepatocellular carcinoma (HCC) with a background of chronic liver disease are limited. Here we describe the use of ALPPS procedure to manage a large solitary HCC with a background of chronic liver disease. The rising incidence of HCC has increased the number of surgical resections in patients with advanced stage liver disease not considered for liver transplantation. We reviewed reported experience of ALPPS in established chronic liver disease and current therapeutic modalities for HCC on a background of chronic liver disease in patients with potential liver insufficiency where tumor burden is beyond liver transplant criteria.
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Affiliation(s)
- Michail Papamichail
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Michail Pizanias
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Vincent Yip
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Evangellos Prassas
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Andreas Prachalias
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Alberto Quaglia
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Praveen Peddu
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Parthi Srinivasan
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
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Vivarelli M, Vincenzi P, Montalti R, Fava G, Tavio M, Coletta M, Vecchi A, Nicolini D, Agostini A, Ali Ahmed E, Giovagnoni A, Mocchegiani F. ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review. PLoS One 2015; 10:e0144019. [PMID: 26700646 PMCID: PMC4689524 DOI: 10.1371/journal.pone.0144019] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/12/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature. METHODS Since January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. RESULTS Until July 2014 ALPPS was completed in 9 patients whose mean age was 60 ± 8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289 ± 122 mL (21.1 ± 5.5%) before ALPPS-1 and 528 ± 121 mL (32.2 ± 5.7%) before ALLPS-2 (p < 0.001). The increase in FLR between the two procedures was 96 ± 47% (range: 24-160%, p < 0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8 ± 2.9 days. The average hospital stay was 24.1 ± 13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1 ± 8.5 months, the overall survival was 89% at 3-6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review. CONCLUSION The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.
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Affiliation(s)
- Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Vincenzi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Giammarco Fava
- Department of Gastroenterology, Polytechnic University of Marche, Ancona, Italy
| | - Marcello Tavio
- Unit of Emerging and Immunosuppressed Infectious Diseases, Department of Gastroenterology and Transplantation, Polytechnic University of Marche, Ancona, Italy
| | - Martina Coletta
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Vecchi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Agostini
- Unit of General and Paediatric Radiology, Department of Radiology, Polytechnic University of Marche, Ancona, Italy
| | - Emad Ali Ahmed
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
- Department of Gastroenterology, Polytechnic University of Marche, Ancona, Italy
- Unit of Emerging and Immunosuppressed Infectious Diseases, Department of Gastroenterology and Transplantation, Polytechnic University of Marche, Ancona, Italy
- Unit of General and Paediatric Radiology, Department of Radiology, Polytechnic University of Marche, Ancona, Italy
- Hepatobiliary and Pancreatic Surgery Unit, Department of General Surgery, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Andrea Giovagnoni
- Unit of General and Paediatric Radiology, Department of Radiology, Polytechnic University of Marche, Ancona, Italy
| | - Federico Mocchegiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
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Adam R, de Gramont A, Figueras J, Kokudo N, Kunstlinger F, Loyer E, Poston G, Rougier P, Rubbia-Brandt L, Sobrero A, Teh C, Tejpar S, Van Cutsem E, Vauthey JN, Påhlman L. Managing synchronous liver metastases from colorectal cancer: a multidisciplinary international consensus. Cancer Treat Rev 2015; 41:729-741. [PMID: 26417845 DOI: 10.1016/j.ctrv.2015.06.006] [Citation(s) in RCA: 390] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 06/23/2015] [Indexed: 02/07/2023]
Abstract
An international panel of multidisciplinary experts convened to develop recommendations for managing patients with colorectal cancer (CRC) and synchronous liver metastases (CRCLM). A modified Delphi method was used. CRCLM is defined as liver metastases detected at or before diagnosis of the primary CRC. Early and late metachronous metastases are defined as those detected ⩽12months and >12months after surgery, respectively. To provide information on potential curability, use of high-quality contrast-enhanced computed tomography (CT) before chemotherapy is recommended. Magnetic resonance imaging is increasingly being used preoperatively to aid detection of subcentimetric metastases, and alongside CT in difficult situations. To evaluate operability, radiology should provide information on: nodule size and number, segmental localization and relationship with major vessels, response after neoadjuvant chemotherapy, non-tumoral liver condition and anticipated remnant liver volume. Pathological evaluation should assess response to preoperative chemotherapy for both the primary tumour and metastases, and provide information on the tumour, margin size and micrometastases. Although the treatment strategy depends on the clinical scenario, the consensus was for chemotherapy before surgery in most cases. When the primary CRC is asymptomatic, liver surgery may be performed first (reverse approach). When CRCLM are unresectable, the goal of preoperative chemotherapy is to downsize tumours to allow resection. Hepatic resection should not be denied to patients with stable disease after optimal chemotherapy, provided an adequate liver remnant with inflow and outflow preservation remains. All patients with synchronous CRCLM should be evaluated by a hepatobiliary multidisciplinary team.
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Affiliation(s)
- René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France.
| | | | - Joan Figueras
- Hepato-biliary and Pancreatic Surgery Unit, Department of Surgery, Dr Josep Trueta Hospital, Institut d'Investigació Biomèdica (IDIBGi), Girona, Spain.
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, University of Tokyo, Tokyo, Japan.
| | - Francis Kunstlinger
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France.
| | - Evelyne Loyer
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Graeme Poston
- Surgery Department, Aintree University Hospital, School of Translational Studies, University of Liverpool, Liverpool, UK.
| | - Philippe Rougier
- Digestive Oncology Department, Hôpital Européen Georges Pompidou, University Paris V-René Descartes and AP-HP Paris, France.
| | - Laura Rubbia-Brandt
- Pathology Department, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland.
| | | | - Catherine Teh
- Liver Centre and Department of Surgery, National Kidney & Transplant Institute, Quezon City, Philippines.
| | - Sabine Tejpar
- Digestive Oncology, University Hospitals Leuven and KU Leuven, Leuven, Belgium.
| | - Eric Van Cutsem
- Digestive Oncology, University Hospitals Leuven and KU Leuven, Leuven, Belgium.
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Lars Påhlman
- Department of Surgical Science, Uppsala University Hospital, Uppsala, Sweden.
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Defining Post Hepatectomy Liver Insufficiency: Where do We stand? J Gastrointest Surg 2015; 19:2079-92. [PMID: 26063080 DOI: 10.1007/s11605-015-2872-6] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/02/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is a major source of morbidity and mortality in patients undergoing liver resection. The aim of this review is to summarize the recent literature available on PHLF including its definition, predictive factors, preoperative risk assessment, severity grading, preventative measures, and management strategies. METHODS A systematic literature search was carried out with the search engines PubMed, Medline, and Cochrane Database using the keywords related to "liver failure", "posthepatectomy", and "hepatic resection". RESULTS Liver resection is a curative treatment of liver tumors. However, it leads to concurrent death and regeneration of the remaining hepatocytes. Factors related to the patient, liver parenchyma and the extent of surgery can inhibit regeneration leading to PHLF. CONCLUSION Given its resistance to treatment and the high postoperative mortality associated with PHLF, great effort has been put in to both accurately identify patients at high risk and to develop strategies that can help prevent its occurrence.
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Herman P, Krüger JAP, Perini MV, Coelho FF, Cecconello I. High Mortality Rates After ALPPS: the Devil Is the Indication. J Gastrointest Cancer 2015; 46:190-194. [PMID: 25682120 DOI: 10.1007/s12029-015-9691-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Paulo Herman
- Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Rua Dr. Enéas de Carvalho Aguiar, 255 - 9° andar - sala 9025, São Paulo, SP, CEP 05403-900, Brazil
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A systematic review and meta-analysis of portal vein ligation versus portal vein embolization for elective liver resection. Surgery 2015; 157:690-8. [DOI: 10.1016/j.surg.2014.12.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 11/30/2014] [Accepted: 12/12/2014] [Indexed: 12/11/2022]
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Fard-Aghaie MH, Stavrou GA, Schuetze KC, Papalampros A, Donati M, Oldhafer KJ. ALPPS and simultaneous right hemicolectomy - step one and resection of the primary colon cancer. World J Surg Oncol 2015; 13:124. [PMID: 25881177 PMCID: PMC4381420 DOI: 10.1186/s12957-015-0544-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 03/11/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Resection of the liver is often limited due to the volume of the parenchyma. To address this problem, several approaches to induce hypertrophy were developed. Recently, the 'associating liver partition and portal vein ligation for staged hepatectomy' (ALPPS) procedure was introduced and led to rapid hypertrophy in a short interval. Additionally to the portal vein occlusion, the parenchyma is transected, which disrupts the inter-parenchymal vascular connections. Since the first description of the ALPPS procedure, various reports around the world were published. In some cases, due to the high morbidity and mortality, a decent oncologic algorithm is not deliverable in a timely manner. If a patient is to be treated with a liver-first approach, the resection of the primary could sometimes be severely protracted. To overcome the problem, a simultaneous resection of the primary tumor and step one of ALPPS were performed. CASE PRESENTATION A 73-year-old male patient underwent portal vein embolization (PVE) after suffering from a synchronous hepatic metastasized carcinoma of the right colic flexure in order to perform a right trisectionectomy. Sufficient hypertrophy could not be obtained by PVE. Thus a 'Rescue-ALPPS' was undertaken. During step one of ALPPS, we simultaneously performed a right hemicolectomy. The postoperative course after the first step was uneventful, and sufficient hypertrophy was achieved. CONCLUSION In order to achieve a macroscopic disease-free state and lead the patient as soon as possible to the oncologic path (with, for example, chemotherapy), sometimes a simultaneous resection of the primary with step one of the ALPPS procedure seems justified. A resection of the primary with step two is not advisable, due to the high morbidity and mortality after this step. This case shows that a simultaneous resection is feasible and safe. Whether other locations of the primary should be treated this way must be part of further investigations.
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Affiliation(s)
- Mohammad H Fard-Aghaie
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Ruebenkamp 220, 22291, Hamburg, Germany.
| | - Gregor A Stavrou
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Ruebenkamp 220, 22291, Hamburg, Germany.
- Semmelweis University, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099, Hamburg, Germany.
| | - Kim C Schuetze
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Ruebenkamp 220, 22291, Hamburg, Germany.
| | - Alexandros Papalampros
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Ruebenkamp 220, 22291, Hamburg, Germany.
| | - Marcello Donati
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Ruebenkamp 220, 22291, Hamburg, Germany.
| | - Karl J Oldhafer
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Ruebenkamp 220, 22291, Hamburg, Germany.
- Semmelweis University, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099, Hamburg, Germany.
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Kwon YJ, Lee KG, Choi D. Clinical implications of advances in liver regeneration. Clin Mol Hepatol 2015; 21:7-13. [PMID: 25834796 PMCID: PMC4379199 DOI: 10.3350/cmh.2015.21.1.7] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 02/16/2015] [Indexed: 12/27/2022] Open
Abstract
Remarkable advances have been made recently in the area of liver regeneration. Even though liver regeneration after liver resection has been widely researched, new clinical applications have provided a better understanding of the process. Hepatic damage induces a process of regeneration that rarely occurs in normal undamaged liver. Many studies have concentrated on the mechanism of hepatocyte regeneration following liver damage. High mortality is usual in patients with terminal liver failure. Patients die when the regenerative process is unable to balance loss due to liver damage. During disease progression, cellular adaptations take place and the organ microenvironment changes. Portal vein embolization and the associating liver partition and portal vein ligation for staged hepatectomy are relatively recent techniques exploiting the remarkable progress in understanding liver regeneration. Living donor liver transplantation is one of the most significant clinical outcomes of research on liver regeneration. Another major clinical field involving liver regeneration is cell therapy using adult stem cells. The aim of this article is to provide an outline of the clinical approaches being undertaken to examine regeneration in liver diseases.
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Affiliation(s)
- Yong Jin Kwon
- Department of Surgery, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Kyeong Geun Lee
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Dongho Choi
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
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Gramignoli R, Vosough M, Kannisto K, Srinivasan RC, Strom SC. Clinical hepatocyte transplantation: practical limits and possible solutions. Eur Surg Res 2015; 54:162-177. [PMID: 25633583 DOI: 10.1159/000369552] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 11/04/2014] [Indexed: 01/05/2025]
Abstract
Since the first human hepatocyte transplants (HTx) in 1992, clinical studies have clearly established proof of principle for this therapy as a treatment for patients with acquired or inherited liver disease. Although major accomplishments have been made, there are still some specific limitations to this technology, which, if overcome, could greatly enhance the efficacy and implementation of this therapy. Here, we describe what in our view are the most significant obstacles to the clinical application of HTx and review the solutions currently proposed. The obstacles of significance include the limited number and quality of liver tissues as a cell source, the lack of clinical grade reagents, quality control evaluation of hepatocytes prior to transplantation, hypothermic storage of cells prior to transplantation, preconditioning treatments to enhance engraftment and proliferation of donor cells, tracking or monitoring cells after transplantation, and the optimal immunosuppression protocols for transplant recipients.
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Affiliation(s)
- Roberto Gramignoli
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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Vennarecci G, Grazi GL, Santoro R, Ettorre GM. A room for the alpps procedure in patients with HCC. Int J Surg 2014; 13:90-91. [PMID: 25500565 DOI: 10.1016/j.ijsu.2014.11.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 11/30/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Giovanni Vennarecci
- Department of General Surgery and Organ Transplantation, San Camillo Hospital, Rome, Italy.
| | - Gian Luca Grazi
- Department of Hepatobiliary Surgery, Regina Elena Cancer Institute, Rome, Italy
| | - Roberto Santoro
- Department of General Surgery and Organ Transplantation, San Camillo Hospital, Rome, Italy
| | - Giuseppe Maria Ettorre
- Department of General Surgery and Organ Transplantation, San Camillo Hospital, Rome, Italy
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Alonso Casado O, González Moreno S, Encinas García S, Rubio González E, Ortega Pérez G. Two-stage right hepatic trisectionectomy with interval portal embolization: another alternative for advanced liver disease with large tumour volume in segment IV and small residual volume. Cir Esp 2014; 93:253-6. [PMID: 25433422 DOI: 10.1016/j.ciresp.2014.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/03/2014] [Accepted: 09/29/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Oscar Alonso Casado
- Unidad de Oncología Quirúrgica Digestiva, MD Anderson Cancer Center Madrid, Madrid, España.
| | | | - Sara Encinas García
- Unidad de Oncología Médica Digestiva, MD Anderson Cancer Center Madrid, Madrid, España
| | - Eduardo Rubio González
- Unidad de Oncología Quirúrgica Digestiva, MD Anderson Cancer Center Madrid, Madrid, España
| | - Gloria Ortega Pérez
- Unidad de Oncología Quirúrgica Digestiva, MD Anderson Cancer Center Madrid, Madrid, España
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