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Schwenk L, Rauchfuss F, Caglayan L, Gkika E, Corradini S, Ernst T, Settmacher U. Multimodale Therapiemöglichkeiten beim oligometastasierten kolorektalen Karzinom. DIE ONKOLOGIE 2025. [DOI: 10.1007/s00761-025-01694-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/26/2025] [Indexed: 04/19/2025]
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Höppener DJ, Aswolinskiy W, Qian Z, Tellez D, Nierop PMH, Starmans M, Nagtegaal ID, Doukas M, de Wilt JHW, Grünhagen DJ, van der Laak JAWM, Vermeulen P, Ciompi F, Verhoef C. Classifying histopathological growth patterns for resected colorectal liver metastasis with a deep learning analysis. BJS Open 2024; 8:zrae127. [PMID: 39471410 PMCID: PMC11523050 DOI: 10.1093/bjsopen/zrae127] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2024] [Revised: 09/09/2024] [Accepted: 09/12/2024] [Indexed: 11/01/2024] Open
Abstract
BACKGROUND Histopathological growth patterns are one of the strongest prognostic factors in patients with resected colorectal liver metastases. Development of an efficient, objective and ideally automated histopathological growth pattern scoring method can substantially help the implementation of histopathological growth pattern assessment in daily practice and research. This study aimed to develop and validate a deep-learning algorithm, namely neural image compression, to distinguish desmoplastic from non-desmoplastic histopathological growth patterns of colorectal liver metastases based on digital haematoxylin and eosin-stained slides. METHODS The algorithm was developed using digitalized whole-slide images obtained in a single-centre (Erasmus MC Cancer Institute, the Netherlands) cohort of patients who underwent first curative intent resection for colorectal liver metastases between January 2000 and February 2019. External validation was performed on whole-slide images of patients resected between October 2004 and December 2017 in another institution (Radboud University Medical Center, the Netherlands). The outcomes of interest were the automated classification of dichotomous hepatic growth patterns, distinguishing between desmoplastic hepatic growth pattern and non-desmoplatic growth pattern by a deep-learning model; secondary outcome was the correlation of these classifications with overall survival in the histopathology manual-assessed histopathological growth pattern and those assessed using neural image compression. RESULTS Nine hundred and thirty-two patients, corresponding to 3.641 whole-slide images, were reviewed to develop the algorithm and 870 whole-slide images were used for external validation. Median follow-up for the development and the validation cohorts was 43 and 29 months respectively. The neural image compression approach achieved significant discriminatory power to classify 100% desmoplastic histopathological growth pattern with an area under the curve of 0.93 in the development cohort and 0.95 upon external validation. Both the histopathology manual-scored histopathological growth pattern and neural image compression-classified histopathological growth pattern achieved a similar multivariable hazard ratio for desmoplastic versus non-desmoplastic growth pattern in the development cohort (histopathology manual score: 0.63 versus neural image compression: 0.64) and in the validation cohort (histopathology manual score: 0.40 versus neural image compression: 0.48). CONCLUSIONS The neural image compression approach is suitable for pathology-based classification tasks of colorectal liver metastases.
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Affiliation(s)
- Diederik J Höppener
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Witali Aswolinskiy
- Departments of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Zhen Qian
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Tellez
- Departments of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pieter M H Nierop
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Martijn Starmans
- Department of Radiology and Nuclear Medicine, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iris D Nagtegaal
- Departments of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johannes H W de Wilt
- Departments of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Peter Vermeulen
- Translational Cancer Research Unit6, GZA Hospital Sint-Augustinus & University of Antwerp, Antwerp, Belgium
| | - Francesco Ciompi
- Departments of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Haddad A, Lendoire M, Maki H, Kang HC, Habibollahi P, Odisio BC, Huang SY, Vauthey JN. Liver volumetry and liver-regenerative interventions: history, rationale, and emerging tools. J Gastrointest Surg 2024; 28:766-775. [PMID: 38519362 DOI: 10.1016/j.gassur.2024.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/26/2024] [Accepted: 02/08/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Postoperative hepatic insufficiency (PHI) is the most feared complication after hepatectomy. Volume of the future liver remnant (FLR) is one objectively measurable indicator to identify patients at risk of PHI. In this review, we summarized the development and rationale for the use of liver volumetry and liver-regenerative interventions and highlighted emerging tools that could yield new advancements in liver volumetry. METHODS A review of MEDLINE/PubMed, Embase, and Cochrane Library databases was conducted to identify literature related to liver volumetry. The references of relevant articles were reviewed to identify additional publications. RESULTS Liver volumetry based on radiologic imaging was developed in the 1980s to identify patients at risk of PHI and later used in the 1990s to evaluate grafts for living donor living transplantation. The field evolved in the 2000s by the introduction of standardized FLR based on the hepatic metabolic demands and in the 2010s by the introduction of the degree of hypertrophy and kinetic growth rate as measures of the FLR regenerative and functional capacity. Several liver-regenerative interventions, most notably portal vein embolization, are used to increase resectability and reduce the risk of PHI. In parallel with the increase in automation and machine assistance to physicians, many semi- and fully automated tools are being developed to facilitate liver volumetry. CONCLUSION Liver volumetry is the most reliable tool to detect patients at risk of PHI. Advances in imaging analysis technologies, newly developed functional measures, and liver-regenerative interventions have been improving our ability to perform safe hepatectomy.
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Affiliation(s)
- Antony Haddad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Mateo Lendoire
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Harufumi Maki
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Hyunseon Christine Kang
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Peiman Habibollahi
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Steven Y Huang
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States.
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Bozkurt E, Sijberden JP, Kasai M, Abu Hilal M. Efficacy and perioperative safety of different future liver remnant modulation techniques: a systematic review and network meta-analysis. HPB (Oxford) 2024; 26:465-475. [PMID: 38245490 DOI: 10.1016/j.hpb.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/20/2023] [Accepted: 01/03/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND In daily clinical practice, different future liver remnant (FLR) modulation techniques are increasingly used to allow a liver resection in patients with insufficient FLR volume. This systematic review and network meta-analysis aims to compare the efficacy and perioperative safety of portal vein ligation (PVL), portal vein embolization (PVE), liver venous deprivation (LVD) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). METHODS A literature search for studies comparing liver resections following different FLR modulation techniques was performed in MEDLINE, Embase and Cochrane Central, and pairwise and network meta-analyses were conducted. RESULTS Overall, 23 studies comprising 1557 patients were included. LVD achieved the greatest increase in FLR (17.32 %, 95% CI 2.49-32.15), while ALPPS was most effective in preventing dropout before the completion hepatectomy (OR 0.29, 95% CI 0.15-0.55). PVL tended to be associated with a longer time to completion hepatectomy (MD 5.78 days, 95% CI -0.67-12.23). Liver failure occurred less frequently after LVD, compared to PVE (OR 0.35, 95% CI 0.14-0.87) and ALPPS (OR 0.28, 95% CI 0.09-0.85). DISCUSSION ALPPS and LVD seem superior to PVE and PVL in terms of achieved FLR increase and subsequent treatment completion. LVD was associated with lower rates of post hepatectomy liver failure, compared to both PVE and ALPPS. A summary of the protocol has been prospectively registered in the PROSPERO database (CRD42022321474).
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Affiliation(s)
- Emre Bozkurt
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy; Department of Surgery, Hepatopancreatobiliary Surgery Division, Koç University Hospital, Istanbul, Turkey
| | - Jasper P Sijberden
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy; Amsterdam UMC Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, Hyogo, Japan
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy; Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
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Werey F, Dembinski J, Michaud A, Sabbagh C, Mauvais F, Yzet T, Regimbeau JM. Right portal vein ligation is still relevant for left hemi-liver hypertrophy: results of a comparative study using a propensity score between right portal vein ligation and embolization. Langenbecks Arch Surg 2023; 409:25. [PMID: 38158401 DOI: 10.1007/s00423-023-03213-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND In two-stage hepatectomy for bilobar liver metastases from colorectal cancer, future liver remnant (FLR) growth can be achieved using several techniques, such as right portal vein ligation (RPVL) or right portal vein embolization (RPVE). A few heterogeneous studies have compared these two techniques with contradictory results concerning FLR growth. The objective of this study was to compare FLR hypertrophy of the left hemi-liver after RPVL and RPVE. STUDY DESIGN This was a retrospective comparative study using a propensity score of patients who underwent RPVL or RPVE prior to major hepatectomy between January 2010 and December 2020. The endpoints were FLR growth (%) after weighting using the propensity score, which included FLR prior to surgery and the number of chemotherapy cycles. Secondary endpoints were the percentage of patients undergoing simultaneous procedures, the morbidity and mortality, the recourse to other liver hypertrophy procedures, and the number of invasive procedures for the entire oncologic program in intention-to-treat analysis. RESULTS Fifty-four consecutive patients were retrospectively included and analyzed, 18 in the RPVL group, and 36 in the RPVE group. The demographic characteristics were similar between the groups. After weighting, there was no significant difference between the RPVL and RPVE groups for FLR growth (%), respectively 32.5% [19.3-56.0%] and 34.5% [20.5-47.3%] (p = 0.221). There was no significant difference regarding the secondary outcomes except for the lower number of invasive procedures in RPVL group (median of 2 [2.0, 3.0] in RPVL group and 3 [3.0, 3.0] in RPVE group, p = 0.001)). CONCLUSION RPVL and RPVE are both effective to provide required left hemi-liver hypertrophy before right hepatectomy. RPVL should be considered for the simultaneous treatment of liver metastases and the primary tumor.
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Affiliation(s)
- Fabien Werey
- Department of Digestive Surgery, Amiens University Medical Center and Jules Verne University of Picardie, 1 Rue du Professeur Christian Cabrol, 80054, Amiens Cedex, France
| | - Jeanne Dembinski
- Department of Digestive Surgery, Amiens University Medical Center and Jules Verne University of Picardie, 1 Rue du Professeur Christian Cabrol, 80054, Amiens Cedex, France
- SSPC UPJV 7518 (Simplifications Des Soins Patients Chirurgicaux Complexes - Simplification of Care of Complex Surgical Patients) Clinical Research Unit, Jules Verne University of Picardie, 80054, Amiens, France
| | - Audrey Michaud
- Department of Methodology, Biostatistics, Direction of Clinical Research, Amiens University Medical Center, Amiens, France
| | - Charles Sabbagh
- Department of Digestive Surgery, Amiens University Medical Center and Jules Verne University of Picardie, 1 Rue du Professeur Christian Cabrol, 80054, Amiens Cedex, France
- SSPC UPJV 7518 (Simplifications Des Soins Patients Chirurgicaux Complexes - Simplification of Care of Complex Surgical Patients) Clinical Research Unit, Jules Verne University of Picardie, 80054, Amiens, France
| | - François Mauvais
- Department of Digestive Surgery, Beauvais General Hospital, 40 Avenue Leon Blum, 60000, Beauvais Cedex, France
| | - Thierry Yzet
- Department of Radiology, Amiens University Medical Center and Jules Verne University of Picardie, 1 Rue du Professeur Christian Cabrol, 80054, Amiens Cedex, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Medical Center and Jules Verne University of Picardie, 1 Rue du Professeur Christian Cabrol, 80054, Amiens Cedex, France.
- SSPC UPJV 7518 (Simplifications Des Soins Patients Chirurgicaux Complexes - Simplification of Care of Complex Surgical Patients) Clinical Research Unit, Jules Verne University of Picardie, 80054, Amiens, France.
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Bekheit M, Grundy L, Salih AK, Bucur P, Vibert E, Ghazanfar M. Post-hepatectomy liver failure: A timeline centered review. Hepatobiliary Pancreat Dis Int 2023; 22:554-569. [PMID: 36973111 DOI: 10.1016/j.hbpd.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection. DATA SOURCES This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black's checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis. RESULTS This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade. CONCLUSIONS Remnant liver volume manipulation is the most consistent preventive measure against PHLF.
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Affiliation(s)
- Mohamed Bekheit
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Institute of Medical Sciences, Medical School, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Hépatica, Integrated Center of HPB Care, Elite Hospital, Agriculture Road, Alexandria, Egypt.
| | - Lisa Grundy
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
| | - Ahmed Ka Salih
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Institute of Medical Sciences, Medical School, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
| | - Petru Bucur
- Department of Surgery, University Hospital Tours, Val de la Loire 37000, France
| | - Eric Vibert
- Centre Hépatobiliaire, Paul Brousse Hospital, 12 Paul Valliant Couturier, 94804 Villejuif, France
| | - Mudassar Ghazanfar
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
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Merath K, Tiwari A, Court C, Parikh A, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Postoperative Liver Failure: Definitions, Risk factors, Prediction Models and Prevention Strategies. J Gastrointest Surg 2023; 27:2640-2649. [PMID: 37783906 DOI: 10.1007/s11605-023-05834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Liver resection is the treatment for a variety of benign and malignant conditions. Despite advances in preoperative selection, surgical technique, and perioperative management, post hepatectomy liver failure (PHLF) is still a leading cause of morbidity and mortality following liver resection. METHODS A review of the literature was performed utilizing MEDLINE/PubMed and Web of Science databases in May of 2023. The MESH terms "liver failure," "liver insufficiency," and "hepatic failure" in combination with "liver surgery," "liver resection," and "hepatectomy" were searched in the title and/or abstract. The references of relevant articles were reviewed to identify additional eligible publications. RESULTS PHLF can have devastating physiological consequences. In general, risk factors can be categorized as patient-related, primary liver function-related, or perioperative factors. Currently, no effective treatment options are available and the management of PHLF is largely supportive. Therefore, identifying risk factors and preventative strategies for PHLF is paramount. Ensuring an adequate future liver remnant is important to mitigate risk of PHLF. Dynamic liver function tests provide more objective assessment of liver function based on the metabolic capacity of the liver and have the advantage of easy administration, low cost, and easy reproducibility. CONCLUSION Given the absence of randomized data specifically related to the management of PHLF, current strategies are based on the principles of management of acute liver failure from any cause. In addition, goal-directed therapy for organ dysfunction, as well as identification and treatment of reversible factors in the postoperative period are critical.
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Affiliation(s)
- Katiuscha Merath
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Ankur Tiwari
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Colin Court
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Alexander Parikh
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA.
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Optimizing Growth of the Future Liver Remnant and Making In-Situ Liver Transsection Safe—A Standardized Approach to ISLT or ALPPS. Curr Oncol 2023; 30:3277-3288. [PMID: 36975462 PMCID: PMC10046923 DOI: 10.3390/curroncol30030249] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
In-situ splitting of the liver before extended resection has gained broad attention. This two-step procedure requires several measures to make an effective and safe procedure. Although the procedure is performed in many institutions, there is no consensus on a uniform technique. The two steps can be divided into different parts and a standardized technique may render the procedure safer and the results will be easier to evaluate. In this paper, we describe a detailed approach to in-situ splitting that allows making both procedures safe, avoids liver necrosis, and is easily reproducible. In the first procedure the portal branches to segments I and IV to VIII are divided, the arterial branches and bile ducts to these segments are preserved and encircled and the parenchyma between segments II/III and IVa/b is divided. This avoids necrosis and bile leaks of segments I and IV and avoids urgent completion operations. In particular, the handling of vital structures close to the dissection line seems important to us. Complete splitting and securing the right and middle hepatic vein will make the second step of this procedure a minimal-risk procedure at a stage where the patient is still recovering from the more demanding first step.
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Portal Vein Embolization: Rationale, Techniques, and Outcomes to Maximize Remnant Liver Hypertrophy with a Focus on Contemporary Strategies. Life (Basel) 2023; 13:life13020279. [PMID: 36836638 PMCID: PMC9959051 DOI: 10.3390/life13020279] [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: 11/30/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Hepatectomy remains the gold standard for curative therapy for patients with limited primary or metastatic hepatic tumors as it offers the best survival rates. In recent years, the indication for partial hepatectomy has evolved away from what will be removed from the patient to the volume and function of the future liver remnant (FLR), i.e., what will remain. With this regard, liver regeneration strategies have become paramount in transforming patients who previously had poor prognoses into ones who, after major hepatic resection with negative margins, have had their risk of post-hepatectomy liver failure minimized. Preoperative portal vein embolization (PVE) via the purposeful occlusion of select portal vein branches to promote contralateral hepatic lobar hypertrophy has become the accepted standard for liver regeneration. Advances in embolic materials, selection of treatment approaches, and PVE with hepatic venous deprivation or concurrent transcatheter arterial embolization/radioembolization are all active areas of research. To date, the optimal combination of embolic material to maximize FLR growth is not yet known. Knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications for PVE, the methods for assessing hepatic lobar hypertrophy, and the possible complications of PVE need to be fully understood before undertaking the procedure. The goal of this article is to discuss the rationale, indications, techniques, and outcomes of PVE before major hepatectomy.
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Yi F, Zhang W, Feng L. Efficacy and safety of different options for liver regeneration of future liver remnant in patients with liver malignancies: a systematic review and network meta-analysis. World J Surg Oncol 2022; 20:399. [PMID: 36527081 PMCID: PMC9756618 DOI: 10.1186/s12957-022-02867-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Several treatments induce liver hypertrophy for patients with liver malignancies but insufficient future liver remnant (FLR). Herein, the aim of this study is to compare the efficacy and safety of existing surgical techniques using network meta-analysis (NMA). METHODS We searched PubMed, Web of Science, and Cochrane Library from databases for abstracts and full-text articles published from database inception through Feb 2022. The primary outcome was the efficacy of different procedures, including standardized FLR (sFLR) increase, time to hepatectomy, resection rate, and R0 resection margin. The secondary outcome was the safety of different treatments, including the rate of Clavien-Dindo≥3a and 90-day mortality. RESULTS Twenty-seven studies, including three randomized controlled trials (RCTs), three prospective trials (PTs), and twenty-one retrospective trials (RTs), and a total number of 2075 patients were recruited in this study. NMA demonstrated that the Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) had much higher sFLR increase when compared to portal vein embolization (PVE) (55.25%, 95% CI 45.27-65.24%), or liver venous deprivation(LVD) (43.26%, 95% CI 22.05-64.47%), or two-stage hepatectomy (TSH) (30.53%, 95% CI 16.84-44.21%), or portal vein ligation (PVL) (58.42%, 95% CI 37.62-79.23%). ALPPS showed significantly shorter time to hepatectomy when compared to PVE (-32.79d, 95% CI -42.92-22.66), or LVD (-34.02d, 95% CI -47.85-20.20), or TSH (-22.85d, 95% CI -30.97-14.72), or PVL (-43.37d, 95% CI -64.11-22.62); ALPPS was considered as the highest resection rate when compared to TSH (OR=6.09; 95% CI 2.76-13.41), or PVL (OR =3.52; 95% CI 1.16-10.72), or PVE (OR =4.12; 95% CI 2.19-7.77). ALPPS had comparable resection rate with LVD (OR =2.20; 95% CI 0.83-5.86). There was no significant difference between them when considering the R0 marge rate. ALPPS had a higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments, although there were no significant differences between different procedures. CONCLUSIONS ALPPS demonstrated a higher regeneration rate, shorter time to hepatectomy, and higher resection rate than PVL, PVE, or TSH. There was no significant difference between them when considering the R0 marge rate. However, ALPPS developed the trend of higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments.
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Affiliation(s)
- Fengming Yi
- Department of Oncology, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China
- JiangXi Key Laboratory of Clinical and Translational Cancer Research, Nanchang, 330006, People's Republic of China
| | - Wei Zhang
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China.
| | - Long Feng
- Department of Oncology, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China.
- JiangXi Key Laboratory of Clinical and Translational Cancer Research, Nanchang, 330006, People's Republic of China.
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Okada M, Ihara K, Miyoshi K, Nakao S, Tanabe M, Tokumitsu Y, Harada E, Sakamoto K, Nagano H, Ito K. Portal vein embolization via the ipsilateral percutaneous transhepatic approach versus laparotomic transileocecal approach: complications, profile and changes in future liver remnant volume. Br J Radiol 2022; 95:20210854. [PMID: 35348358 PMCID: PMC10996331 DOI: 10.1259/bjr.20210854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Major liver resection is an effective treatment option for patients with liver malignancy. The future liver remnant (FLR) volume and complications after portal vein embolization (PVE) were compared between the ipsilateral right portal vein (PTPE) and transileocolic (TIPE) approaches. METHODS A total of 42 patients (TIPE, n = 22; PTPE, n = 20) underwent right lobectomy after PVE. CT and hepatobiliary scintigraphy were repeated before and after PVE. The blood examination findings and the FLR values (FLRCT: calculated from CT, %FLRCT: FLRCT ratio, %FLRSPECT: FLR ratio using single photon emission CT, FLRCT/BS: FLRCT to body surface ratio) were compared between two approach sites. The complications and mortality were also analyzed after PVE and major right hepatectomy. RESULTS There were no significant differences in the patient characteristics, blood examination findings or FLR values between two groups. Adequate liver regeneration was observed without significant differences between PTPE and TIPE (increased ratio of FLRCT: 8.7% vs 19.2%, p = 0.15 [25-75 percentile: 17.1-60.4], %FLRCT: 11.2% vs 8.3%, p = 0.25 [6.3-13.3], %FLRSPECT: 15.4% vs 19.2%, p = 0.09 [16.0-22.4], FLRCT/BS: 33.6% vs 47.1%, p = 0.19 [17.2-60.4], respectively), but TIPE required a significantly longer procedure time than PTPE [181.4 min vs 108.7 min, p < 0.01 (103.3-193.5)]. However, one patient was converted to TIPE due to bleeding during PTPE. After right lobectomy, portal vein stenosis or thrombosis was noted in three patients [two with TIPE (9.1%) and one with PTPE (5%)] and three TIPE patients died within 90 days (13.6%) after right hepatectomy. CONCLUSION FLR volume significantly increased after PVE, regardless of the approach sites; however, PTPE is a useful technique with a shorter procedure time.
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Affiliation(s)
- Munemasa Okada
- Department of Radiology, National Hospital Organization, Kanmon
Medical Center, Shimonoseki,
Japan
| | - Kenichiro Ihara
- Department of Radiology, Yamaguchi University Graduate School
of Medicine, Ube,
Japan
| | - Keisuke Miyoshi
- Department of Radiology, Yamaguchi University Graduate School
of Medicine, Ube,
Japan
| | - Sei Nakao
- Department of Surgery and Clinical Science, Yamaguchi
University Graduate School of Medicine,
Ube, Japan
| | - Masahiro Tanabe
- Department of Radiology, Yamaguchi University Graduate School
of Medicine, Ube,
Japan
| | - Yukio Tokumitsu
- Department of Gastroenterological, Breast and Endocrine
Surgery, Yamaguchi University Graduate School of Medicine,
Ube, Japan
| | - Eijiro Harada
- Department of Surgery and Clinical Science, Yamaguchi
University Graduate School of Medicine,
Ube, Japan
| | - Kazuhiko Sakamoto
- Department of Surgery, National Hospital Organization, Kanmon
Medical Center, Shimonoseki,
Japan
| | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine
Surgery, Yamaguchi University Graduate School of Medicine,
Ube, Japan
| | - Katsuyoshi Ito
- Department of Radiology, Yamaguchi University Graduate School
of Medicine, Ube,
Japan
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12
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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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13
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Hedrick TL, Zaydfudim VM. Management of Synchronous Colorectal Cancer Metastases. Surg Oncol Clin N Am 2022; 31:265-278. [DOI: 10.1016/j.soc.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Haberman DM, Andriani OC, Segaran NL, Volpacchio MM, Micheli ML, Russi RH, Pérez Fernández IA. Role of CT in Two-Stage Liver Surgery. Radiographics 2022; 42:106-124. [PMID: 34990325 DOI: 10.1148/rg.210067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Complete resection is the only potentially curative treatment for primary or metastatic liver tumors. Improvements in surgical techniques such as conventional two-stage hepatectomy (TSH) with portal vein embolization and ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) promote hypertrophy of the future liver remnant (FLR), expanding resection criteria to include patients with widespread hepatic disease who were formerly not considered candidates for resection. Radiologists are essential in the multidisciplinary approach required for TSH. In particular, multidetector CT has a critical role throughout the various stages of this surgical process. The aims of CT before the first stage of TSH are to define the feasibility of surgery, assess the number and location of liver tumors in relation to relevant anatomy, and provide a detailed anatomic evaluation, including vascular and biliary variants. Volume calculation with CT is also essential to determine if the FLR is sufficient to avoid posthepatectomy liver failure. The objectives of CT between the first and second stages of TSH are to recalculate liver volumes (ie, assess FLR hypertrophy) and depict expected liver changes and complications that could modify the surgical plan or preclude the second stage of definitive resection. In this review, the importance of CT throughout different stages of TSH is discussed and key observations that contribute to surgical planning are highlighted. In addition, the advantages and limitations of MRI for detection of liver metastases and assessment of complications are briefly described. ©RSNA, 2022.
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Affiliation(s)
- Diego M Haberman
- From the Body Imaging Section, Centro de Diagnóstico Rossi, Esmeralda 141, Buenos Aires C1035ABD, Argentina (D.M.H., M.M.V., M.L.M.); Oncosurgical HPB Unit, Sanatorio de los Arcos, Swiss Medical Group, HPB, Buenos Aires, Argentina (O.C.A., R.H.R., I.A.P.F.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (N.L.S.)
| | - Oscar C Andriani
- From the Body Imaging Section, Centro de Diagnóstico Rossi, Esmeralda 141, Buenos Aires C1035ABD, Argentina (D.M.H., M.M.V., M.L.M.); Oncosurgical HPB Unit, Sanatorio de los Arcos, Swiss Medical Group, HPB, Buenos Aires, Argentina (O.C.A., R.H.R., I.A.P.F.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (N.L.S.)
| | - Nicole L Segaran
- From the Body Imaging Section, Centro de Diagnóstico Rossi, Esmeralda 141, Buenos Aires C1035ABD, Argentina (D.M.H., M.M.V., M.L.M.); Oncosurgical HPB Unit, Sanatorio de los Arcos, Swiss Medical Group, HPB, Buenos Aires, Argentina (O.C.A., R.H.R., I.A.P.F.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (N.L.S.)
| | - Mariano M Volpacchio
- From the Body Imaging Section, Centro de Diagnóstico Rossi, Esmeralda 141, Buenos Aires C1035ABD, Argentina (D.M.H., M.M.V., M.L.M.); Oncosurgical HPB Unit, Sanatorio de los Arcos, Swiss Medical Group, HPB, Buenos Aires, Argentina (O.C.A., R.H.R., I.A.P.F.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (N.L.S.)
| | - Maria Lucrecia Micheli
- From the Body Imaging Section, Centro de Diagnóstico Rossi, Esmeralda 141, Buenos Aires C1035ABD, Argentina (D.M.H., M.M.V., M.L.M.); Oncosurgical HPB Unit, Sanatorio de los Arcos, Swiss Medical Group, HPB, Buenos Aires, Argentina (O.C.A., R.H.R., I.A.P.F.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (N.L.S.)
| | - Rodolfo H Russi
- From the Body Imaging Section, Centro de Diagnóstico Rossi, Esmeralda 141, Buenos Aires C1035ABD, Argentina (D.M.H., M.M.V., M.L.M.); Oncosurgical HPB Unit, Sanatorio de los Arcos, Swiss Medical Group, HPB, Buenos Aires, Argentina (O.C.A., R.H.R., I.A.P.F.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (N.L.S.)
| | - Ignacio A Pérez Fernández
- From the Body Imaging Section, Centro de Diagnóstico Rossi, Esmeralda 141, Buenos Aires C1035ABD, Argentina (D.M.H., M.M.V., M.L.M.); Oncosurgical HPB Unit, Sanatorio de los Arcos, Swiss Medical Group, HPB, Buenos Aires, Argentina (O.C.A., R.H.R., I.A.P.F.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (N.L.S.)
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15
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Del Basso C, Gaillard M, Lainas P, Zervaki S, Perlemuter G, Chagué P, Rocher L, Voican CS, Dagher I, Tranchart H. Current strategies to induce liver remnant hypertrophy before major liver resection. World J Hepatol 2021; 13:1629-1641. [PMID: 34904033 PMCID: PMC8637666 DOI: 10.4254/wjh.v13.i11.1629] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/08/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatic resection is the gold standard for patients affected by primary or metastatic liver tumors but is hampered by the risk of post-hepatectomy liver failure. Despite recent improvements, liver surgery still requires excellent clinical judgement in selecting patients for surgery and, above all, efficient pre-operative strategies to provide adequate future liver remnant. The aim of this article is to review the literature on the rational, the preliminary assessment, the advantages as well as the limits of each existing technique for preparing the liver for major hepatectomy.
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Affiliation(s)
- Celeste Del Basso
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Martin Gaillard
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Stella Zervaki
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Gabriel Perlemuter
- Department of Hepato-Gastroenterology and Nutrition, Antoine Béclère Hospital, Clamart 92140, France
| | - Pierre Chagué
- Department of Radiology, Antoine Béclère Hospital, Clamart 92140, France
| | - Laurence Rocher
- Department of Radiology, Antoine Béclère Hospital, Clamart 92140, France
| | - Cosmin Sebastian Voican
- Department of Hepato-Gastroenterology and Nutrition, Antoine Béclère Hospital, Clamart 92140, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
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Chansangrat J, Keeratibharat N. Portal vein embolization: rationale, techniques, outcomes and novel strategies. Hepat Oncol 2021; 8:HEP42. [PMID: 34765107 PMCID: PMC8577518 DOI: 10.2217/hep-2021-0006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/08/2021] [Indexed: 12/14/2022] Open
Abstract
The incidence of liver cancer has grown in the past decade, with 905,677 new cases and 830,180 deaths in 2020. According to the highest annual fatality ratio, liver cancer is the third-leading cause of cancer-related deaths worldwide. Surgical resection is the mainstay treatment for long-term survival. However, only 25% of patients are surgical candidates. Recent surgical concepts, techniques and multidisciplinary management were developed, including interventional radiology procedures that improve the management algorithm, expand the indications and limit dropouts from curative treatment. This review summarizes up-to-date information on interventional radiology in the management of liver tumors.
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Affiliation(s)
- Jirapa Chansangrat
- School of Radiology, Institute of Medicine, Suranaree University of Technology, 30000, Thailand
| | - Nattawut Keeratibharat
- School of Surgery, Institute of Medicine, Suranaree University of Technology, 30000, Thailand
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17
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Nebelung H, Wolf T, Bund S, Radosa CG, Plodeck V, Grosche-Schlee S, Riediger C, Hoffmann RT, Kühn JP. Radioembolization versus portal vein embolization for contralateral liver lobe hypertrophy: effect of cirrhosis. Abdom Radiol (NY) 2021; 46:4046-4055. [PMID: 33779787 PMCID: PMC8286933 DOI: 10.1007/s00261-021-03048-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 10/24/2022]
Abstract
PURPOSE Preoperative hypertrophy induction of future liver remnant (FLR) reduces the risk of postoperative liver insufficiency after partial hepatectomy. One of the most commonly used methods to induce hypertrophy of FLR is portal vein embolization (PVE). Recent studies have shown that transarterial radioembolization (TARE) also induces hypertrophy of the contralateral liver lobe. The aim of our study was to evaluate contralateral hypertrophy after TARE versus after PVE taking into account the effect of cirrhosis. METHODS Forty-nine patients undergoing PVE before hemihepatectomy and 24 patients with TARE as palliative treatment for liver malignancy were retrospectively included. Semi-automated volumetry of the FLR/contralateral liver lobe before and after intervention (20 to 65 days) was performed on CT or MRI, and the relative increase in volume was calculated. Cirrhosis was evaluated independently by two radiologists on CT/MRI, and interrater reliability was calculated. RESULTS Hypertrophy after PVE was significantly more pronounced than after TARE (25.3% vs. 7.4%; p < 0.001). In the subgroup of patients without cirrhosis, the difference was also statistically significant (25.9% vs. 8.6%; p = 0.002), whereas in patients with cirrhosis, the difference was not statistically significant (18.2% vs. 7.4%; p = 0.212). After PVE, hypertrophy in patients without cirrhosis was more pronounced than in patients with cirrhosis (25.9% vs. 18.2%; p = 0.203), while after TARE, hypertrophy was comparable in patients with and without cirrhosis (7.4% vs. 8.6%; p = 0.928). CONCLUSION TARE induces less pronounced hypertrophy of the FLR compared to PVE. Cirrhosis seems to be less of a limiting factor for hypertrophy after TARE, compared to PVE.
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18
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The evolution of surgery for colorectal liver metastases: A persistent challenge to improve survival. Surgery 2021; 170:1732-1740. [PMID: 34304889 DOI: 10.1016/j.surg.2021.06.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/01/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
Only a few decades ago, the opinion that colorectal liver metastases were a palliative diagnosis changed. In fact, previously, the prevailing view was strongly resistant against resecting colorectal liver metastases. Constant technical improvement of liver surgery and, much later, effective chemotherapy allowed for a successful wider application of surgery. The clinical use of portal vein embolization was the starting signal of regenerative liver surgery, where insufficient liver volume can be expanded to an extent where safe resection is possible. Today, a number of these techniques including portal vein ligation, associating liver partition and portal vein ligation for staged hepatectomy, and bi-embolization (portal and hepatic vein) can be successfully used to address an insufficient future liver remnant in staged resections. It turned out that the road to success is embedding surgery in a well-orchestrated oncological concept of controlling systemic disease. This concept was the prerequisite that meant liver transplantation could enter the treatment strategy for colorectal liver metastases, ending up with a 5-year overall survival of 80% in highly selected cases. In particular, techniques combining principles of 2-stage hepatectomy and liver transplantation, such as "resection and partial liver segment 2-3 transplantation with delayed total hepatectomy" (RAPID) are on the rise. These techniques enable the use of partial liver grafts with primarily insufficient liver volume. All this progress also prompted a number of innovative local therapies to address recurrences ultimately transferring colorectal liver metastases from instantly deadly into a chronic disease in some cases.
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Memeo R, Conticchio M, Deshayes E, Nadalin S, Herrero A, Guiu B, Panaro F. Optimization of the future remnant liver: review of the current strategies in Europe. Hepatobiliary Surg Nutr 2021; 10:350-363. [PMID: 34159162 DOI: 10.21037/hbsn-20-394] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Liver resection still represent the treatment of choice for liver malignancies, but in some cases inadequate future remnant liver (FRL) can lead to post hepatectomy liver failure (PHLF) that still represents the most common cause of death after hepatectomy. Several strategies in recent era have been developed in order to generate a compensatory hypertrophy of the FRL, reducing the risk of post hepatectomy liver failure. Portal vein embolization, portal vein ligation, and ALLPS are the most popular techniques historically adopted up to now. The liver venous deprivation and the radio-embolization are the most recent promising techniques. Despite even more precise tools to calculate the relationship among volume and function, such as scintigraphy with 99mTc-mebrofenin (HBS), no consensus is still available to define which of the above mentioned augmentation strategy is more adequate in terms of kind of surgery, complexity of the pathology and quality of liver parenchyma. The aim of this article is to analyse these different strategies to achieve sufficient FRL.
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Affiliation(s)
- Riccardo Memeo
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, "F. Miulli" General Hospital, Acquaviva delle Fonti, Bari, Italy
| | | | - Emmanuel Deshayes
- Department of Nuclear Medicine, Institute du Cancer de Montpellier (ICM), Montpellier, France.,INSERM U1194, Montpellier Cancer Research Institute, Montpellier University, Montpellier, France
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Germany
| | - Astrid Herrero
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, St-Eloi University Hospital, Montpellier, France
| | - Boris Guiu
- INSERM U1194, Montpellier Cancer Research Institute, Montpellier University, Montpellier, France.,Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, St-Eloi University Hospital, Montpellier, France
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MRI-Based Quantitation of Hepatic Steatosis Does Not Predict Hypertrophy Rate after Portal Vein Embolization in Patients with Colorectal Liver Metastasis and Normal to Moderately Elevated Fat Fraction. J Clin Med 2021; 10:jcm10092003. [PMID: 34067008 PMCID: PMC8125629 DOI: 10.3390/jcm10092003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 02/08/2023] Open
Abstract
The aim of this study was to correlate the pre-procedural magnetic-resonance-imaging-based hepatic fat fraction (hFF) with the degree of hypertrophy after portal vein embolization (PVE) in patients with colorectal cancer liver metastases (CRCLM). Between 2011 November and 2020 February, 68 patients with CRCLM underwent magnetic resonance imaging (MRI; 1.5 Tesla) of the liver before PVE. Using T1w chemical shift imaging (DUAL FFE), the patients were categorized as having a normal (<5%) or an elevated (>5%) hFF. The correlation of hFF, age, gender, initial tumor mass, history of chemotherapy, degree of liver hypertrophy, and kinetic growth rate after PVE was investigated using multiple regression analysis and Spearman’s test. A normal hFF was found in 43/68 patients (63%), whereas 25/68 (37%) patients had an elevated hFF. The mean hypertrophy and kinetic growth rates in patients with normal vs. elevated hFF were 24 ± 31% vs. 28 ± 36% and 9 ± 9 % vs. 8 ± 10% (p > 0.05), respectively. Spearman’s test showed no correlation between hFF and the degree of hypertrophy (R = −0.04). Multivariable analysis showed no correlation between hFF, history of chemotherapy, age, baseline tumor burden, or laterality of primary colorectal cancer, and only a poor inverse correlation between age and kinetic growth rate after PVE. An elevated hFF in a pre-procedural MRI does not correlate with the hypertrophy rate after PVE and should therefore not be used as a contraindication to the procedure in patients with CRCLM.
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21
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Induction of liver hypertrophy for extended liver surgery and partial liver transplantation: State of the art of parenchyma augmentation-assisted liver surgery. Langenbecks Arch Surg 2021; 406:2201-2215. [PMID: 33740114 PMCID: PMC8578101 DOI: 10.1007/s00423-021-02148-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Background Liver surgery and transplantation currently represent the only curative treatment options for primary and secondary hepatic malignancies. Despite the ability of the liver to regenerate after tissue loss, 25–30% future liver remnant is considered the minimum requirement to prevent serious risk for post-hepatectomy liver failure. Purpose The aim of this review is to depict the various interventions for liver parenchyma augmentation–assisting surgery enabling extended liver resections. The article summarizes one- and two-stage procedures with a focus on hypertrophy- and corresponding resection rates. Conclusions To induce liver parenchymal augmentation prior to hepatectomy, most techniques rely on portal vein occlusion, but more recently inclusion of parenchymal splitting, hepatic vein occlusion, and partial liver transplantation has extended the technical armamentarium. Safely accomplishing major and ultimately total hepatectomy by these techniques requires integration into a meaningful oncological concept. The advent of highly effective chemotherapeutic regimen in the neo-adjuvant, interstage, and adjuvant setting has underlined an aggressive surgical approach in the given setting to convert formerly “palliative” disease into a curative and sometimes in a “chronic” disease.
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22
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Gautier S, Chevallier O, Mastier C, d'Athis P, Falvo N, Pilleul F, Midulla M, Rat P, Facy O, Loffroy R. Portal vein embolization with ethylene-vinyl alcohol copolymer for contralateral lobe hypertrophy before liver resection: safety, feasibility and initial experience. Quant Imaging Med Surg 2021; 11:797-809. [PMID: 33532278 DOI: 10.21037/qims-20-808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background To report our preliminary experience with preoperative portal vein embolization (PVE) using liquid ethylene vinyl alcohol (EVOH) copolymer. Methods Retrospectively review of patients with primary or secondary liver malignancies scheduled for extensive hepatectomy after the induction of future liver remnant (FLR) hypertrophy by right or left PVE with EVOH as the only embolic agent between 2014 and 2018 at two academic centers. Cross-sectional imaging liver volumetry data obtained before and 3-6 weeks after PVE were used to assess the FLR volume (FLRV) increase, degree of FLR hypertrophy and the FLR kinetic growth rate (KGR). Results Twenty-six patients (17 males; mean age, 58.7±11 years; range, 32-79 years) were included. The technical and clinical success rate was 100%. PVE produced adequate FLR hypertrophy in all patients. Embolization occurred in all targeted portal branches and in no non-target vessels. The %FLRV increased by 52.9%±32.5% and the degree of FLR hypertrophy was 16.7%±6.8%. The KGR was 4.4%±2.0% per week. Four patients experience minor complications after PVE which resolved with symptomatic treatment. The resection rate was 84.5%. One patient died during surgery for reasons unrelated to PVE. Conclusions Preoperative PVE with EVOH copolymer is feasible, safe, and effective in inducing FLR hypertrophy.
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Affiliation(s)
- Sébastien Gautier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, Dijon, France
| | - Charles Mastier
- Department of Interventional Radiology and Oncology, Léon Bérard Cancer Center, Lyon, France
| | - Philippe d'Athis
- Department of Epidemiology and Biostatistics, François-Mitterrand University Hospital, Dijon, France
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, Dijon, France
| | - Frank Pilleul
- Department of Interventional Radiology and Oncology, Léon Bérard Cancer Center, Lyon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, Dijon, France
| | - Patrick Rat
- Department of Digestive and Oncologic Surgery, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Facy
- Department of Digestive and Oncologic Surgery, François-Mitterrand University Hospital, Dijon, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, Dijon, France
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Ali A, Ahle M, Björnsson B, Sandström P. Portal vein embolization with N-butyl cyanoacrylate glue is superior to other materials: a systematic review and meta-analysis. Eur Radiol 2021; 31:5464-5478. [PMID: 33501598 DOI: 10.1007/s00330-020-07685-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/16/2020] [Accepted: 12/31/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVES It remains uncertain which embolization material is best for portal vein embolization (PVE). We investigated the various materials for effectiveness in inducing future liver remnant (FLR) hypertrophy, technical and growth success rates, and complication and resection rates. METHODS A systematic review from 1998 to 2019 on embolization materials for PVE was performed on Pubmed, Embase, and Cochrane. FLR growth between the two most commonly used materials was compared in a random effects meta-analysis. In a separate analysis using local data (n = 52), n-butyl cyanoacrylate (NBCA) was compared with microparticles regarding costs, radiation dose, and procedure time. RESULTS In total, 2896 patients, 61.0 ± 4.0 years of age and 65% male, from 51 papers were included in the analysis. In 61% of the patients, either NBCA or microparticles were used for embolization. The remaining were treated with ethanol, gelfoam, or sclerosing agents. The FLR growth with NBCA was 49.1% ± 29.7 compared to 42.2% ± 40 with microparticles (p = 0.037). The growth success rate with NBCA vs microparticles was 95.3% vs 90.7% respectively (p < 0.001). There were no differences in major complications between NBCA and microparticles. In the local analysis, NBCA (n = 41) entailed shorter procedure time and reduced fluoroscopy time (p < 0.001), lower radiation exposure (p < 0.01), and lower material costs (p < 0.0001) than microparticles (n = 11). CONCLUSION PVE with NBCA seems to be the best choice when combining growth of the FLR, procedure time, radiation exposure, and costs. KEY POINTS • The meta-analysis shows that n-butyl cyanoacrylate (NBCA) is superior to microparticles regarding hypertrophy of the future liver remnant, 49.1% ± 29.7 vs 42.2% ± 40.0 (p = 0.037). • There is no significant difference in major complication rates for portal vein embolization using NBCA, 4% (24/681), compared with microparticles, 5% (25/494) (p > 0.05). • Local data shows a shorter procedure time, 215 vs 348 mins from arrival to departure at the interventional radiology unit, and fluoroscopy time, 43 vs 96 mins (p < 0.001), lower radiation dosage, 573 vs 1287 Gycm2 (p < 0.01), and costs, €816 vs €4233 (p < 0.0001) for NBCA compared to microparticles.
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Affiliation(s)
- Adnan Ali
- Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, UK.
| | - Margareta Ahle
- Department of Radiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Bergthor Björnsson
- Department of Surgery and Clinical and Experimental Medicine, University Hospital of Linköping, Linköping, Sweden
| | - Per Sandström
- Department of Surgery and Clinical and Experimental Medicine, University Hospital of Linköping, Linköping, Sweden
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Gavriilidis P, Sutcliffe RP, Roberts KJ, Pai M, Spalding D, Habib N, Jiao LR, Sodergren MH. No difference in mortality among ALPPS, two-staged hepatectomy, and portal vein embolization/ligation: A systematic review by updated traditional and network meta-analyses. Hepatobiliary Pancreat Dis Int 2020; 19:411-419. [PMID: 32753333 DOI: 10.1016/j.hbpd.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is an ongoing debate on the feasibility, safety, and oncological efficacy of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. The aim of this study was to compare ALPPS, two-staged hepatectomy (TSH), and portal vein embolization (PVE)/ligation (PVL) using updated traditional meta-analysis and network meta-analysis (NMA). DATA SOURCES Electronic databases were used in a systematic literature search. Updated traditional meta-analysis and NMA were performed and compared. Mortality and major morbidity were selected as primary outcomes. RESULTS Nineteen studies including 1200 patients were selected from the pool of 436 studies. Of these patients, 315 (31%) and 702 (69%) underwent ALPPS and portal vein occlusion (PVO), respectively. Ninety-day mortality based on updated traditional meta-analysis, subgroup analysis of the randomized controlled trials (RCTs), and both Bayesian and frequentist NMA did not demonstrate significant differences between the ALPPS cohort and the PVE, PVL, and TSH cohorts. Moreover, analysis of RCTs did not demonstrate significant differences of major morbidity between the ALPPS and PVO cohorts. The ALPPS cohort demonstrated significantly more favorable outcomes in hypertrophy parameters, time to operation, definitive hepatectomy, and R0 margins rates compared with the PVO cohort. In contrast, 1-year disease-free survival was significantly higher in the PVO cohort compared to the ALPPS cohort. CONCLUSIONS This study is the first to use updated traditional meta-analysis and both Bayesian and frequentist NMA and demonstrated no significant differences in 90-day mortality between the ALPPS and other hepatic hypertrophy approaches. Furthermore, two high quality RCTs including 147 patients demonstrated no significant differences in major morbidity between the ALPPS and PVO cohorts.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK.
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Keith J Roberts
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Madhava Pai
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Duncan Spalding
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Nagy Habib
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Long R Jiao
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Mikael H Sodergren
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
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Kishore SA, Bajwa R, Madoff DC. Embolotherapeutic Strategies for Hepatocellular Carcinoma: 2020 Update. Cancers (Basel) 2020; 12:791. [PMID: 32224882 PMCID: PMC7226474 DOI: 10.3390/cancers12040791] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 02/07/2023] Open
Abstract
Hepatocellular carcinoma (HCC) represents a significant contributor to cancer-related morbidity and mortality with increasing incidence in both developing and developed countries. Embolotherapy as a locoregional therapeutic strategy consists of trans-arterial or "bland" embolization (TAE), trans-arterial chemoembolization (TACE), and selective internal radiotherapy (SIRT). Trans-catheter arterial therapies can be applied along all stages of HCC, either as an alternative or neoadjuvant to surgical resection/transplantation in very early and early stage HCC or as a palliative option for local disease control in unresectable and advanced stage HCC. In advanced stage HCC, SIRT did not demonstrate superiority in comparison to systemic treatment options in several recent large prospective trials, though for carefully selected patients, may confer improved tolerability with similar disease control rates. The latest embolotherapeutic techniques and literature as they pertain to the management of HCC, as well as future directions, are reviewed in this article.
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Affiliation(s)
- Sirish A. Kishore
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA; (S.A.K.); (R.B.)
| | - Raazi Bajwa
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA; (S.A.K.); (R.B.)
| | - David C. Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT 06520, USA
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Abstract
Colorectal cancer (CRC) is one of the most common cancers in the world. About two third of patients with CRC will develop distant recurrence at some point in time. Liver is the most common site where distant metastasis takes place. While the overall survival (OS) of patients with metastatic CRC was poor about 3 decades ago, there has been tremendous improvement in this area in the recent years. With the advent of effective systemic chemotherapy and biologic agents and better understanding of the biological behaviour of the tumour, aggressive treatment strategies such as metastatectomy of the liver metastases (or lung metastases) are now acceptable. More importantly, it has transformed the way how stage IV CRCs are being managed. From predominantly palliative as the primary aim, a comprehensive multidisciplinary approach is now the mainstay of treatment with very successful outcomes. Combination of systemic therapies with liver resection has been shown to be effective in providing promising survival benefits. In addition, other adjunctive modalities in targeting the liver metastases such as ablation, combining resection and ablation, transarterial chemoembolization, stereotactic body radiotherapy (SBRT), hepatic artery perfusion, etc. have also been demonstrated variable outcome in treating colorectal liver metastasis (CRLM). Very recently, transplant oncologists have also explored using liver transplantation as a treatment modality for unresectable CRLM, which has demonstrated very good long-term survival in well selected cases. The new paradigm in the treatment of metastatic CRC has dawned.
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Affiliation(s)
- Alfred Wei Chieh Kow
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System, Singapore, Singapore.,Department of Surgery, National University of Singapore, Singapore, Singapore
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27
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Huang HC, Bian J, Bai Y, Lu X, Xu YY, Sang XT, Zhao HT. Complete or partial split in associating liver partition and portal vein ligation for staged hepatectomy: A systematic review and meta-analysis. World J Gastroenterol 2019; 25:6016-6024. [PMID: 31660037 PMCID: PMC6815793 DOI: 10.3748/wjg.v25.i39.6016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 09/17/2019] [Accepted: 09/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been adopted by liver surgeons in recent years. However, high morbidity and mortality rates have limited the promotion of this technique. Some recent studies have suggested that ALPPS with a partial split can effectively induce the growth of future liver remnant (FLR) similar to a complete split with better postoperative safety profiles. However, some others have suggested that ALPPS can induce more rapid and adequate FLR growth, but with the same postoperative morbidity and mortality rates as in partial split of the liver parenchyma in ALPPS (p-ALPPS).
AIM To perform a systematic review and meta-analysis on ALPPS and p-ALPPS.
METHODS A systematic literature search of PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov was performed for articles published until June 2019. Studies comparing the outcomes of p-ALPPS and ALPPS for a small FLR in consecutive patients were included. Our main endpoints were the morbidity, mortality, and FLR hypertrophy rates. We performed a subgroup analysis to evaluate patients with and without liver cirrhosis. We assessed pooled data using a random-effects model.
RESULTS Four studies met the inclusion criteria. Four studies reported data on morbidity and mortality, and two studies reported the FLR hypertrophy rate and one study involved patients with cirrhosis. In the non-cirrhotic group, p-ALPPS-treated patients had significantly lower morbidity and mortality rates than ALPPS-treated patients [odds ratio (OR) = 0.2; 95% confidence interval (CI): 0.07–0.57; P = 0.003 and OR = 0.16; 95%CI: 0.03-0.9; P = 0.04]. No significant difference in the FLR hypertrophy rate was observed between the two groups (P > 0.05). The total effects indicated no difference in the FLR hypertrophy rate or perioperative morbidity and mortality rates between the ALPPS and p-ALPPS groups. In contrast, ALPPS seemed to have a better outcome in the cirrhotic group.
CONCLUSION The findings of our study suggest that p-ALPPS is safer than ALPPS in patients without cirrhosis and exhibits the same rate of FLR hypertrophy.
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Affiliation(s)
- Han-Chun Huang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jin Bian
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yi Bai
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xin Lu
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yi-Yao Xu
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xin-Ting Sang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Hai-Tao Zhao
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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28
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ALPPS Improves Resectability Compared With Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastasis: Results From a Scandinavian Multicenter Randomized Controlled Trial (LIGRO Trial). Ann Surg 2019; 267:833-840. [PMID: 28902669 PMCID: PMC5916470 DOI: 10.1097/sla.0000000000002511] [Citation(s) in RCA: 221] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: The aim of the study was to evaluate if associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) could increase resection rates (RRs) compared with two-stage hepatectomy (TSH) in a randomized controlled trial (RCT). Background: Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails due to insufficient liver growth or tumor progression. Methods: A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of less than 30%. Primary outcome—RRs were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality, and 90-day mortality measured from the final intervention. Results: Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% [95% confidence interval (CI) 84%–100%] (44/48) in the ALPPS arm compared with 57% (95% CI 43%–72%) (28/49) in the TSH arm [rate ratio 8.25 (95% CI 2.6–26.6); P < 0.0001]. No differences in complications (Clavien–Dindo ≥3a) [43% (19/44) vs 43% (12/28)] [1.01 (95% CI 0.4–2.6); P = 0.99], 90-day mortality [8.3% (4/48) vs 6.1% (3/49)] [1.39 [95% CI 0.3–6.6]; P = 0.68] or R0 RRs [77% (34/44) vs 57% (16/28)] [2.55 [95% CI 0.9–7.1]; P = 0.11)] were observed. Of the patients in the TSH arm that failed to reach an sFLR of 30%, 12 were successfully treated with ALPPS. Conclusion: ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications, and short-term mortality.
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29
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Albati NA, Korairi AA, Al Hasan I, Almodhaiberi HK, Algarni AA. Outcomes of staged hepatectomies for liver malignancy. World J Hepatol 2019; 11:513-521. [PMID: 31293719 PMCID: PMC6603508 DOI: 10.4254/wjh.v11.i6.513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/27/2019] [Accepted: 06/18/2019] [Indexed: 02/06/2023] Open
Abstract
Liver malignancies are the fifth most common cause of death worldwide. Surgical intervention with curative intent is the treatment of choice for liver tumors as it provides long-term survival. However, only 20% of patients with metastatic liver lesions can be managed by curative liver resection. In most of the cases, hepatectomy is not feasible because of insufficient future liver remnant (FLR). Two-stage hepatectomy is advocated to achieve liver resection in a patient who is considered to not be a candidate for resection. Procedures of staged hepatectomy include conventional two-stage hepatectomy, portal vein embolization, and associating liver partition and portal vein ligation for a staged hepatectomy. Technical success is high for each of these procedures but variable between them. All the procedures have been reported as being effective in achieving a satisfactory FLR and completing the second-stage resection. Moreover, the overall survival and disease-free survival rates have improved significantly for patients who were otherwise considered nonresectable; yet, an increase in the morbidity and mortality rates has been observed. We suggest that this type of procedure should be carried out in high-flow centers and through a multidisciplinary approach. An experienced surgeon is key to the success of those interventions.
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Affiliation(s)
- Naif A Albati
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Ali A Korairi
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Ibrahim Al Hasan
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Helayel K Almodhaiberi
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Abdullah A Algarni
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
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30
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Kow AWC. Transplantation versus liver resection in patients with hepatocellular carcinoma. Transl Gastroenterol Hepatol 2019; 4:33. [PMID: 31231700 DOI: 10.21037/tgh.2019.05.06] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/08/2019] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common solid cancers in the world. Its treatment strategies have evolved significantly over the past few decades but the best treatment outcomes remain in the surgical arena. Especially for early HCCs, the options are abundant. However, surgical resection and liver transplantation provide the best long-term survival. In addition, there are evidence the ablative therapy such as radiofrequency ablation, could provide equivalent outcome as compared to resection. However, HCC is a unique malignancy as the majority of patients develop this cancer in the background of cirrhotic livers. As such, the treatment consideration should not only look at the oncological perspective but also the functional status of the liver parenchyma, i.e., the state of cirrhosis and presence of portal hypertension. Even with the most widely adopted staging systems for HCC such as the Barcelona Clinic Liver Cancer (BCLC) staging system and many other staging systems, none of them are ideal in including the various considerations for patients with HCCs. In this article, the key issues between choosing surgical resection and liver transplantation are discussed. A comprehensive review of the current surgical options are outlined in order to explore the pros and cons of each option.
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Affiliation(s)
- Alfred Wei Chieh Kow
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System Singapore, Singapore.,Department of Surgery, National University of Singapore, Singapore
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31
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Kawaguchi Y, Lillemoe HA, Vauthey JN. Dealing with an insufficient future liver remnant: Portal vein embolization and two-stage hepatectomy. J Surg Oncol 2019; 119:594-603. [PMID: 30825223 DOI: 10.1002/jso.25430] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/09/2019] [Indexed: 12/18/2022]
Abstract
Colorectal liver metastases (CLM) are not always resectable at the time of diagnosis. An insufficient future liver remnant is a factor excluding patients from curative intent resection. To deal with this issue, two-stage hepatectomy was introduced approximately 20 years ago. It is a sequential treatment strategy for bilateral CLM, which consists of preoperative chemotherapy, portal vein embolization, and planned first and second liver resections. This study reviews current evidence supporting use of two-stage hepatectomy.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heather A Lillemoe
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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32
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Kumar N, Duncan T, O'Reilly D, Káposztás Z, Parry C, Rees J, Junnarkar S. Partial ALPPS with a longer wait between procedures is safe and yields adequate future liver remnant hypertrophy. Ann Hepatobiliary Pancreat Surg 2019; 23:13-19. [PMID: 30863803 PMCID: PMC6405373 DOI: 10.14701/ahbps.2019.23.1.13] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/23/2018] [Accepted: 07/26/2018] [Indexed: 12/14/2022] Open
Abstract
Backgrounds/Aims Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has generated controversy due to high morbidity and mortality. We present our series of patients with 30-40% parenchymal transection and minimal hilar dissection. Methods Patients who had partial ALPPS between April 2015 and April 2016 were included. Patients with colorectal liver metastases (CRLM) had their future liver remnants (FLR) cleared with metastasectomies. The liver was divided along the future line of transection to 30-40%, right portal vein was stapled and divided without extensive hilar dissection, with minimal handling of right liver, which was not mobilised. We preserved the middle hepatic vein. Data were collected prospectively for hypertrophy of the FLR, morbidity and mortality. Results Among the 8 patients (age 25-68) investigated, one patient with cholangiocarcinoma had portal vein embolization prior to partial ALPPS. All patients completed two stages with adequate FLR hypertrophy at a median of 28 days. No mortality was found. The median length of stay after stages 1 and 2 was 9 and 9.6 days, respectively. The median increase in FLR was 38%. Conclusions A limited transection of 30-40%, minimal hilar dissection and longer wait between stages yielded adequate FLR hypertrophy with low morbidity and no mortality.
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Affiliation(s)
- Nagappan Kumar
- Cardiff Liver Unit, University Hospital of Wales, Cardiff, UK
| | - Trish Duncan
- Cardiff Liver Unit, University Hospital of Wales, Cardiff, UK
| | - David O'Reilly
- Cardiff Liver Unit, University Hospital of Wales, Cardiff, UK
| | | | - Craig Parry
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - John Rees
- Department of Radiology, University Hospital of Wales, Cardiff, UK
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Future Liver Remnant (FLR) Increase in Patients with Colorectal Liver Metastases Is Highest the First Week After Portal Vein Occlusion : FLR Increase in Patients with CRLM Is Highest the First Week After PVO. J Gastrointest Surg 2019; 23:556-562. [PMID: 30465187 PMCID: PMC6414468 DOI: 10.1007/s11605-018-4031-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/21/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Portal vein occlusion (PVO) is an established method to increase the volume of the future liver remnant (FLR). The main reasons for not proceeding to radical hepatectomy are lack of volume increase and tumor progression due to a wait-time interval of up to 8 weeks. The hypothesis was that the increase in FLR volume is not linear and is largest during the first weeks. METHODS Patients with colorectal liver metastases (CRLM) and standardized future liver remnant (sFLR) < 30% treated with PVO were prospectively included. All patients had at least one CT evaluation before radical hepatectomy. RESULTS Forty-eight patients were included. During the first week after PVO, the kinetic growth rate (KGR) was 5.4 (± 4), compared to 1.5 (± 2) between the first and second CT (p < 0.05). For patients reaching adequate FLR and therefore treated with radical hepatectomy, the KGR was 7 (± 4) the first week, compared to 4.3 (± 2) for patients who failed to reach a sufficient volume (p = 0.4). During the interval between the first and second CT, the KGR was 2.2 (± 2), respectively (± 0.1) (p = 0.017). DISCUSSION The increase in liver volume after PVO is largest during the first week. As KGR decreases over time, it is important to shorten the interval between PVO and the first volume evaluation; this may aid in decision-making and reduce unnecessary waiting time.
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Ray S, Mehta N, Golhar A, Nundy S. Post hepatectomy liver failure - A comprehensive review of current concepts and controversies. Ann Med Surg (Lond) 2018; 34:4-10. [PMID: 30181871 PMCID: PMC6120608 DOI: 10.1016/j.amsu.2018.08.012] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/24/2018] [Accepted: 08/14/2018] [Indexed: 02/06/2023] Open
Abstract
Post hepatectomy liver failure (PHLF) comprises of a conundrum of symptoms and signs following major hepatic resections. The pathophysiology essentially revolves around disruption of the normal hepatocyte regeneration and disturbed liver homeostasis. Prompt identification of the pre-operative predictors of PHLF in the form of biochemical parameters and imaging features are of paramount importance for any hepatic surgeon and forms the cornerstone of its management. Treatment revolves around a goal-directed resuscitation of the systemic organ failure. Auxiliary support systems such as liver dialysis devices and stem cell therapy are still under investigational trials for treatment of the same. Orthotopic liver transplantation (OLT) is the last resort in most cases not responding to other measures.
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Affiliation(s)
- S. Ray
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
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35
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Le Roy B, Dupré A, Gallon A, Chabrot P, Gagnière J, Buc E. Liver hypertrophy: Underlying mechanisms and promoting procedures before major hepatectomy. J Visc Surg 2018; 155:393-401. [PMID: 30126801 DOI: 10.1016/j.jviscsurg.2018.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Various procedures can promote hypertrophy of the future liver remnant (FLR) before major hepatectomy to prevent postoperative liver failure. The pathophysiological situation following portal vein embolization (PVE), hepatic artery ligation/embolization or hepatectomy remains unclear. On one hand, the main mechanisms of hepatic regeneration appear to be driven by hepatic hypoxia (involving the hepatic arterial buffer response), an increased portal blood flow inducing shear stress and the involvement of several mediators (inflammatory cytokines, vasoregulators, growth factors, eicosanoids and several hormones). On the other hand, several factors are associated with impaired liver regeneration, such as biliary obstruction, malnutrition, diabetes mellitus, male gender, age, ethanol and viral infection. All these mechanisms may explain the varying degrees of hypertrophy observed following a surgical or radiological procedure promoting hypertrophy the FLR. Radiological procedures include left and right portal vein embolization (extended or not to segment 4), sequential PVE and hepatic vein embolization (HVE), and more recently combined PVE and HVE. Surgical procedures include associated liver partition and portal vein ligation for staged hepatectomy, and more recently the combined portal embolization and arterial ligation procedure. This review aimed to clarify the pathophysiology of liver regeneration; it also describes radiological or surgical procedures employed to improve liver regeneration in terms of volumetric changes, the feasibility of the second step and the benefits and drawbacks of each procedure.
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Affiliation(s)
- B Le Roy
- Department of Digestive and Hepatobiliary Surgery, Hôpital Estaing, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France; UMR Auvergne UMR 6602 UCA/CNRS/SIGMA, Clermont-Ferrand Faculty of Medicine, 28, place Henri-Dunant, 63000 Clermont-Ferrand, France.
| | - A Dupré
- Inserm, LabTAU UMR1032, Centre Léon-Bérard, Université Claude-Bernard Lyon 1, 69003 Lyon, France
| | - A Gallon
- Department of Vascular Radiology, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, place Henri-Dunant, 63000 Clermont-Ferrand, France; UMR Auvergne UMR 6602 UCA/CNRS/SIGMA, Clermont-Ferrand Faculty of Medicine, 28, place Henri-Dunant, 63000 Clermont-Ferrand, France
| | - P Chabrot
- Department of Vascular Radiology, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, place Henri-Dunant, 63000 Clermont-Ferrand, France; UMR Auvergne UMR 6602 UCA/CNRS/SIGMA, Clermont-Ferrand Faculty of Medicine, 28, place Henri-Dunant, 63000 Clermont-Ferrand, France
| | - J Gagnière
- Department of Digestive and Hepatobiliary Surgery, Hôpital Estaing, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France
| | - E Buc
- Department of Digestive and Hepatobiliary Surgery, Hôpital Estaing, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand, France; UMR Auvergne UMR 6602 UCA/CNRS/SIGMA, Clermont-Ferrand Faculty of Medicine, 28, place Henri-Dunant, 63000 Clermont-Ferrand, France
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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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Uribe M, Uribe-Echevarría S, Mandiola C, Zapata MI, Riquelme F, Romanque P. Insight on ALPPS - Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy - mechanisms: activation of mTOR pathway. HPB (Oxford) 2018; 20:729-738. [PMID: 29571618 DOI: 10.1016/j.hpb.2018.02.636] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 02/21/2018] [Accepted: 02/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND ALPPS procedure has been introduced to increase the volume of future liver remnant. The mechanisms underlying the accelerated regeneration observed with ALPPS are unknown. It was hypothesized that AMPK/mTOR is activated as an integrating pathway for metabolic signals leading to proliferation and cell growth. Our aim was to analyze increase in liver volume, proliferation parameters and expression of AMPK/mTOR pathway-related molecules in patients undergoing ALPPS. METHODS A single center prospective study of patients undergoing ALPPS was performed from 2013 to 2015. Liver and serum samples, clinical laboratory results and CT-scan data were obtained. ELISA, Ki-67 immunostaining and qRT-PCR were performed in deportalized and remnant liver tissue in both stages of the procedure. RESULTS 11 patients were enrolled. Remnant liver volume increased 112 ± 63% (p < 0.05) in 9.1 ± 1.6 days. Proliferation-related cytokines IL-6, TNF-α, HGF and EGF significantly increased, while higher Ki-67 immunostaining and cyclin D expression were observed in remnant livers after ALPPS. mTOR, S6K1, 4E-BP1, TSC1 and TSC2 expression were significantly increased in remnant livers at second stage, while AMPK and Akt increased only in deportalized liver samples. CONCLUSION Rapid liver regeneration with ALPPS might be associated with hepatocyte proliferation induced by mTOR pathway activation.
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Affiliation(s)
- Mario Uribe
- Department of Surgery, Hospital del Salvador, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Sebastián Uribe-Echevarría
- Department of Surgery, Hospital del Salvador, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Carlos Mandiola
- Biomedical Sciences Institute, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - María I Zapata
- Biomedical Sciences Institute, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Francisco Riquelme
- Department of Surgery, Hospital del Salvador, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Pamela Romanque
- Biomedical Sciences Institute, Faculty of Medicine, Universidad de Chile, Santiago, Chile.
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Odisio BC, Simoneau E, Holmes AA, Conrad CH, Vauthey JN. Fast-Track Two-Stage Hepatectomy Using a Hybrid Interventional Radiology/Operating Suite as Alternative Option to Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy Procedure. J Am Coll Surg 2018; 227:e5-e10. [PMID: 29729926 DOI: 10.1016/j.jamcollsurg.2018.04.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/19/2018] [Accepted: 04/19/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Eve Simoneau
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alex A Holmes
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudius H Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Portal Vein Embolization Utilizing N-Butyl Cyanoacrylate for Contralateral Lobe Hypertrophy Prior to Liver Resection: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2018; 41:1302-1312. [PMID: 29687262 DOI: 10.1007/s00270-018-1964-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 04/10/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE To evaluate the safety and effectiveness of n-butyl cyanoacrylate (NBCA) for portal vein embolization (PVE) when used to induce contralateral future liver remnant (FLR) hypertrophy in patients undergoing planned hepatic resection for hepatic malignancy. MATERIALS AND METHODS The PubMed database (including articles indexed by MEDLINE) was searched for articles published from 1970 to 2018 describing patients treated with PVE utilizing NBCA to induce hypertrophy of the FLR prior to contralateral hepatic lobe resection. Demographic data, embolization technique, complications of embolization, resultant FLR hypertrophy, and surgical outcomes were obtained when available. A meta-analysis was performed to determine the cumulative relative hypertrophy rate of the FLR following PVE with NBCA. RESULTS The literature search yielded 18 relevant articles. Six hundred and seven patients (383 men, 220 women; mean age 60.7 years) with procedures describing PVE utilizing NBCA were reviewed. The most common underlying hepatic malignancies were colorectal metastases (n = 348), followed by cholangiocarcinomas (n = 92), and hepatocellular carcinomas (n = 89). Technical success was reportedly achieved in 603/607 patients, for a success rate of 99.3%. Fixed effects meta-analysis of the relative hypertrophy rate of the FLR among studies resulted in an aggregate rate of 49.4 ± 1.3%. Of the patients who underwent attempted PVE, 461/607 (75.9%) eventually underwent surgical resection. Major complications following PVE occurred in 19 patients (3.13%), while minor complications following PVE occurred in 38 patients (6.26%). CONCLUSIONS PVE utilizing NBCA to induce hypertrophy of the FLR prior to contralateral lobe resection in the setting of hepatic malignancy is safe and effective. LEVEL OF EVIDENCE Level IIa-Systematic review of cohort studies.
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Khan AS, Garcia-Aroz S, Ansari MA, Atiq SM, Senter-Zapata M, Fowler K, Doyle MB, Chapman WC. Assessment and optimization of liver volume before major hepatic resection: Current guidelines and a narrative review. Int J Surg 2018; 52:74-81. [PMID: 29425829 DOI: 10.1016/j.ijsu.2018.01.042] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 01/20/2018] [Accepted: 01/29/2018] [Indexed: 02/06/2023]
Abstract
Post hepatectomy liver failure (PHLF) remains a significant cause of morbidity and mortality after major liver resection. Although the etiology of PHLF is multifactorial, an inadequate functional liver remnant (FLR) is felt to be the most important modifiable predictor of PHLF. Pre-operative evaluation of FLR function and volume is of paramount importance before proceeding with any major liver resection. Patients with inadequate or borderline FLR volume must be considered for volume optimization strategies such as portal vein embolization (PVE), two stage hepatectomy with portal vein ligation (PVL), Yttrium-90 radioembolization, and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This paper provides an overview of assessing FLR volume and function, and discusses indications and outcomes of commonly used volume optimization strategies.
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Affiliation(s)
- Adeel S Khan
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA.
| | - Sandra Garcia-Aroz
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
| | | | - Syed M Atiq
- Sanford University of South Dakota Medical Center, Sioux Falls, SD, USA
| | - Michael Senter-Zapata
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
| | - Kathryn Fowler
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
| | - M B Doyle
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
| | - W C Chapman
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
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Stockmann M, Bednarsch J, Malinowski M, Blüthner E, Pratschke J, Seehofer D, Jara M. Functional considerations in ALPPS - consequences for clinical management. HPB (Oxford) 2017; 19:1016-1025. [PMID: 28844397 DOI: 10.1016/j.hpb.2017.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/28/2017] [Accepted: 07/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Since perioperative morbidity and mortality in ALPPS are extraordinarily high, a deeper understanding of actual liver function during the procedure is essential to make the approach safer. METHODS Data from 17 patients who underwent ALLPS were analyzed regarding their course of liver function capacity assessed with the LiMAx test and compared to an equal-sized matched cohort of patients that underwent PVE. RESULTS A comparison of LiMAx prior to and following ALPPS Step I (330 [258-385] vs. 197 [144-224] μg/kg/h, p = 0.003) and prior to and following PVE (386 [330-519] vs. 378 [336-455] μg/kg/h, p = 0.534) demonstrated a significant drop in function after ALLPS. A volume/function analysis predicting FLR function regarding step II revealed an excellent correlation of predicted versus assessed postoperative liver function with a mean relative difference of 9 (-6 to 18)% and an ICC of 0.905 (123 [74-138] vs. 107 [77-175] μg/kg/h, p = 0.310). CONCLUSIONS We provide evidence that liver function capacity is significantly impaired due to ALPPS step I. This is particularly notable when compared to PVE. Our data also shows that the portal ligated liver lobe still continues to contribute significantly to overall liver function. Therefore, FLR function after step II is still predictable by volume/function analysis.
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Affiliation(s)
- Martin Stockmann
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jan Bednarsch
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Maciej Malinowski
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Elisabeth Blüthner
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Daniel Seehofer
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Maximilian Jara
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
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Greater hypertrophy can be achieved with associating liver partition with portal vein ligation for staged hepatectomy compared to conventional staged hepatectomy, but with a higher price to pay? Am J Surg 2017; 215:131-137. [PMID: 28859921 DOI: 10.1016/j.amjsurg.2017.08.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 08/12/2017] [Accepted: 08/21/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) and conventional staged hepatectomy (CSH) are options for patients with unresectable liver tumors due to insufficient future liver remnant (FLR). METHODS A retrospective comparison of clinical data, liver volumetry and surgical outcomes between 10 ALPPS and 29 CSH patients was performed. RESULTS Patient demographics and disease characteristics were similar between both groups. ALPPS induced superior FLR growth (ALPPS vs. CSH, 48.1% (IQR 39.4-96.9%) vs. 11.8% (IQR 4.3-41.9%), p = 0.013). However, post-operative day 5 international normalized ratio (INR) (ALPPS vs. CSH, 1.6 (IQR 1.5-1.8) vs. 1.4 (IQR 1.3-1.6), p = 0.015) and rate of post-hepatectomy liver failure (ALPPS vs. CSH, 25 vs. 0%, p = 0.032) was higher in the ALPPS group. 90-day mortality (ALPPS vs. CSH, 12.5% vs. 0%, p = 0.320) was similar in both groups. CONCLUSION ALPPS was superior in inducing FLR growth but associated with increased post-hepatectomy liver failure compared to CSH.
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Firat O, Makay O, Yeniay L, Gokce G, Yenisey C, Coker A. Omega-3 fatty acids inhibit oxidative stress in a rat model of liver regeneration. Ann Surg Treat Res 2017; 93:1-10. [PMID: 28706885 PMCID: PMC5507785 DOI: 10.4174/astr.2017.93.1.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/02/2016] [Accepted: 12/12/2016] [Indexed: 12/20/2022] Open
Abstract
Purpose Lipid peroxidation and consequent reactive oxygen species in the setting of oxidative stress have crucial roles in liver regeneration, which may adversely affect the regeneration itself and lead to liver failure. The aim of the current study is to investigate whether omega-3 fatty acid supplementation inhibits oxidative stress in an experimental model of liver regeneration. Methods Forty rats were allocated to four groups. Rats in group A received a sham operation. Rats in group B were subjected to right portal vein ligation (RPVL) and saline infusion. Rats in groups C and D were subjected to RPVL and total parenteral nutrition (TPN) with an all-in-one admixture containing a soybean oil based lipid emulsion. Rats in group D were additionally supplemented with omega-3 fatty acid infusion. Oxidative stresses in the blood and liver were measured by glutathione, superoxide dismutase, catalase, glutathione peroxidase, malondialdehyde, and nitric oxide. Results Omega-3 supplementation to the TPN solution significantly corrected alterations in the blood and tissue concentrations of oxidants and anti-oxidants during regeneration (P < 0.05). Conclusion Omega-3 fatty acid supplementation to the TPN solution revealed promising results in removal of oxidative stress that emerges during liver regeneration.
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Affiliation(s)
- Ozgur Firat
- Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Ozer Makay
- Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Levent Yeniay
- Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Goksel Gokce
- Department of Pharmacology, Faculty of Pharmacy, Ege University, Izmir, Turkey
| | - Cigdem Yenisey
- Department of Medical Biochemistry, Adnan Menderes University Hospital, Aydın, Turkey
| | - Ahmet Coker
- Department of General Surgery, Ege University Hospital, Izmir, Turkey
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Senger S, Sperling J, Oberkircher B, Schilling MK, Kollmar O, Menger MD, Ziemann C. Portal branch ligation does not counteract the inhibiting effect of temsirolimus on extrahepatic colorectal metastatic growth. Clin Exp Metastasis 2017. [PMID: 28631253 DOI: 10.1007/s10585-017-9852-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] [Indexed: 11/26/2022]
Abstract
The mTor-inhibitor temsirolimus (TEM) has potent anti-tumor activities on extrahepatic colorectal metastases. Treatment of patients with advanced disease may require portal branch ligation (PBL). While PBL can induce intrahepatic tumor growth, the effect of PBL on extrahepatic metastases under TEM treatment is unknown. Therefore, we analyzed the effects of TEM treatment on extrahepatic metastases during PBL-associated liver regeneration. GFP-transfected CT26.WT colorectal cancer cells were implanted into the dorsal skinfold chamber of BALB/c-mice. Mice were randomized to four groups (n = 8). One was treated daily with TEM (1.5 mg/kg), PBS-treated animals served as controls. Another group underwent PBL of the left liver lobe and received daily TEM treatment. Animals with PBL and PBS treatment served as controls. Tumor vascularization and growth as well as tumor cell migration, proliferation and apoptosis were studied over 14 days. In non-PBL animals TEM treatment inhibited tumor cell proliferation as well as vascularization and growth of the extrahepatic metastases. PBL did not influence tumor cell engraftment, vascularization and metastatic growth. Of interest, TEM treatment significantly reduced tumor cell engraftment, neovascularization and metastatic groth also after PBL. PBL does not counteract the inhibiting effect of TEM on extrahepatic colorectal metastatic growth.
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Affiliation(s)
- Sebastian Senger
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
- Department of Neurosurgery, Saarland University, Homburg/Saar, Germany
| | - Jens Sperling
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Barbara Oberkircher
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Martin K Schilling
- Department of General, Visceral, Vascular and Pediatric Surgery, Saarland University, Homburg/Saar, Germany
- Klinik St. Anna Ärztehaus Lützelmatt, Lucerne, Switzerland
| | - Otto Kollmar
- Department of General, Visceral, Vascular and Pediatric Surgery, Saarland University, Homburg/Saar, Germany
- Department of General and Visceral Surgery, Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Michael D Menger
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Christian Ziemann
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany.
- Department of General, Visceral, Vascular and Pediatric Surgery, Saarland University, Homburg/Saar, Germany.
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center, University of Freiburg, Freiburg, Germany.
- Department of General, Visceral, Vascular and Pediatric Surgery and Institute for Clinical and Experimental Surgery, Saarland Medical School, Saarland University, Kirrberger Straße 1, 66424, Homburg/Saar, Germany.
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Isfordink CJ, Samim M, Braat MNGJA, Almalki AM, Hagendoorn J, Borel Rinkes IHM, Molenaar IQ. Portal vein ligation versus portal vein embolization for induction of hypertrophy of the future liver remnant: A systematic review and meta-analysis. Surg Oncol 2017; 26:257-267. [PMID: 28807245 DOI: 10.1016/j.suronc.2017.05.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/05/2017] [Accepted: 05/07/2017] [Indexed: 02/08/2023]
Abstract
An important risk of major hepatic resection is postoperative liver failure, which is directly related to insufficient future liver remnant (FLR). Portal vein embolization (PVE) and portal vein ligation (PVL) can minimize this risk by inducing hypertrophy of the FLR. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of PVE and PVL for FLR hypertrophy. A systematic search was conducted on the17th of January 2017. The methodological quality of the studies was assessed using the Oxford Critical Appraisal Skills Program for cohort studies. The primary endpoint was the relative rate of hypertrophy of the FLR. Number of cancelled hepatic resection and postoperative morbidity and mortality were secondary endpoints. For meta-analysis, the pooled hypertrophy rate was calculated for each intervention. The literature search identified 21 eligible studies with 1953 PVE and 123 PVL patients. All studies were included in the meta-analysis. No significant differences were found regarding the rate of FLR hypertrophy (PVE 43.2%, PVL 38.5%, p = 0.39). The number of cancelled hepatic resections due to inadequate hypertrophy was significantly lower after PVL (p = 0.002). No differences were found in post-intervention mortality and morbidity. This meta-analysis demonstrated no significant differences in safety and rate of FLR hypertrophy between PVE and PVL. PVE should be considered as the preferred strategy, since it is a minimally invasive procedure. However, during a two-stage procedure, PVL can be performed with expected comparable outcome as PVE.
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Affiliation(s)
- C J Isfordink
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Samim
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Dept. of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M N G J A Braat
- Dept. of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A M Almalki
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J Hagendoorn
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I H M Borel Rinkes
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Q Molenaar
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Regimbeau JM, Cosse C, Kaiser G, Hubert C, Laurent C, Lapointe R, Isoniemi H, Adam R. Feasibility, safety and efficacy of two-stage hepatectomy for bilobar liver metastases of colorectal cancer: a LiverMetSurvey analysis. HPB (Oxford) 2017; 19:396-405. [PMID: 28343889 DOI: 10.1016/j.hpb.2017.01.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 12/29/2016] [Accepted: 01/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The combination of liver resection and chemotherapy has become the standard of care for colorectal liver metastases (LM). The objective of the present study was to evaluate the impact of two-stage hepatectomy (TSH) on the long-term survival of patients with bilobar LM. METHODS We included adult (over-18) patients from the LiverMetSurvey registry with confirmed multiple colorectal LM and having undergone either one-stage hepatectomy or TSH with curative intent. The "TSH (2/2)" group (n = 625) comprised patients having completed both stages of TSH; the "TSH (1/2)" group (n = 244) comprised patients having undergone only the first stage of TSH; the "hepatectomy" group. The primary outcome criterion was the overall survival (OS). The secondary outcomes were the morbidity and mortality rates. RESULTS The 30- and 90-day mortality rates were respectively 3.8% and 9.3% in the TSH (2/2) group, 9.4% and 16.4% in the TSH (1/2) group, and 5.4% and 9.1% in the "hepatectomy" group. The three-year OS rate was 45% in the TSH (2/2) group, 30% in the TSH (1/2) group and 50.7% in the hepatectomy group. CONCLUSION The LiverMetSurvey registry's data indicate that TSH is associated with rather good long-term survival and acceptable morbidity and mortality rates.
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Affiliation(s)
- Jean Marc Regimbeau
- Digestive and Oncological Surgery Department, Amiens University Medical Center, Amiens, France; EA 4292, Jules Verne University of Picardy, Amiens, France; Clinical Research Center, Amiens University Medical Center, Amiens, France.
| | - Cyril Cosse
- Digestive and Oncological Surgery Department, Amiens University Medical Center, Amiens, France; Clinical Research Center, Amiens University Medical Center, Amiens, France
| | | | | | | | | | - Helen Isoniemi
- Transplantation and Liver Surgery Helsinki University Hospital, Helsinki, Finland
| | - Rene Adam
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris (APHP), Hôpital Universitaire Paul Brousse, Villejuif, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 935, Villejuif, France
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Hasselgren K, Malagò M, Vyas S, Campos RR, Brusadin R, Linecker M, Petrowsky H, Clavien PA, Machado MA, Hernandez-Alejandro R, Wanis K, Valter L, Sandström P, Björnsson B. Neoadjuvant chemotherapy does not affect future liver remnant growth and outcomes of associating liver partition and portal vein ligation for staged hepatectomy. Surgery 2017; 161:1255-1265. [PMID: 28081953 DOI: 10.1016/j.surg.2016.11.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/09/2016] [Accepted: 11/30/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The only potentially curative treatment for patients with colorectal liver metastases is hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy has emerged as a method of treatment for patients with inadequate future liver remnant. One concern about associating liver partition and portal vein ligation for staged hepatectomy is that preoperative chemotherapy may negatively affect the volume increase of the future liver remnant and outcomes. METHODS This study from the International Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Registry (NCT01924741) includes 442 patients with colorectal liver metastases registered from 2012-2016. Future liver remnant hypertrophy (absolute increase, percent increase, and kinetic growth rate) and clinical outcome were analyzed retrospectively in relation to type and amount of chemotherapy. The analyzed groups included patients with no chemotherapy, 1 regimen of chemotherapy, >1 regimen, and a group that received monoclonal antibodies in addition to chemotherapy. RESULTS Ninety percent of the patients received neoadjuvant oncologic therapy including 42% with 1 regimen of chemotherapy, 44% with monoclonal antibodies, and 4% with >1 regimen. Future liver remnant increased between 74-92% with the largest increase in the group with 1 regimen of chemotherapy. The increase in milliliters was between 241 mL (>1 regimen) and 306 mL (1 regimen). Kinetic growth rate was between 14-18% per week and was greatest for the group with 1 regimen of chemotherapy. No statistical significance was found between the groups with any of the measurements of future liver remnant hypertrophy. CONCLUSION Neoadjuvant chemotherapy, including monoclonal antibodies, does not negatively affect future liver remnant growth. Patients with colorectal liver metastases who might be potential candidates for associating liver partition and portal vein ligation for staged hepatectomy should be considered for neoadjuvant chemotherapy.
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Affiliation(s)
- Kristina Hasselgren
- Department of Surgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Massimo Malagò
- Department of Hepatopancreaticobiliary Surgery and Liver Transplantation, Division of Surgical and Interventional Sciences, University College London, Royal Free Hospital, London, United Kingdom
| | - Soumil Vyas
- Department of Hepatopancreaticobiliary Surgery and Liver Transplantation, Division of Surgical and Interventional Sciences, University College London, Royal Free Hospital, London, United Kingdom
| | - Ricardo Robles Campos
- Department of General Surgery, Liver Transplant Unit, Virgen De La Arrixaca University Hospital, Murcia, Spain
| | - Roberto Brusadin
- Department of General Surgery, Liver Transplant Unit, Virgen De La Arrixaca University Hospital, Murcia, Spain
| | - Michael Linecker
- Department of Surgery and Transplantation, Swiss Hepatopancreaticobiliary and Transplant Center Zürich, University Hospital Zürich, Zürich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss Hepatopancreaticobiliary and Transplant Center Zürich, University Hospital Zürich, Zürich, Switzerland
| | - Pierre Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepatopancreaticobiliary and Transplant Center Zürich, University Hospital Zürich, Zürich, Switzerland
| | | | | | - Kerollos Wanis
- Department of Surgery, Western University, London, Ontario, Canada
| | - Lars Valter
- Research and Development Unit in Local Healthcare, Linköping University, Linköping, Sweden
| | - Per Sandström
- Department of Surgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Bergthor Björnsson
- Department of Surgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
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Xu HW, Li HY, Liu F, Wei YG, Li B. Totally laparoscopic associating liver tourniquet and portal vein occlusion for staged hepatectomy combined with simultaneous left hemicolectomy for bilateral liver metastases of the primary colon cancer: A case report. Medicine (Baltimore) 2017; 96:e6368. [PMID: 28296776 PMCID: PMC5369931 DOI: 10.1097/md.0000000000006368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Resection of the liver is often limited to the insufficient future liver remnant (FLR). To address this problem, the modification surgical technique "associating liver tourniquet and portal vein occlusion for staged hepatectomy" (ALTPS) was developed and led to quick hypertrophy in a short interval. In some colorectal cancer patients with multiple and bilobar metastases, the resection of the primary is often protracted immensely to the unpredictable postoperative complications for whom is to be treated with a liver-first approach. To overcome this problem, a simultaneous resection of the primary tumor and totally laparoscopic ALTPS for bilateral liver metastases of the primary colon cancer were performed. CASE SUMMARY A 63-year-old female patient with left colon cancer and synchronous bilateral colorectal liver metastases underwent a totally laparoscopic ALTPS and simultaneous left hemicolectomy because of the small FLR. The operative times were 460 minutes for the first stage and 240 minutes for the second stage without the need for blood transfusions. The recoveries after the first and the second operations were uneventful, and the patient was discharged on postoperative day 11 of the second stage operation. CONCLUSION Our case shows the totally laparoscopic ALTPS and simultaneous left hemicolectomy at step 1 for bilobar liver metastases of the primary colon cancer with no severe postoperative complications. If a resection of the primary tumor does not compromise the split procedure, the combination of pure laparoscopic ALTPS and primary resection is feasible and safe.
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Affiliation(s)
- Hong-wei Xu
- Department of Liver Surgery, Center of Liver Transplantation
| | - Hong-yu Li
- Department of Pancreatic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Fei Liu
- Department of Liver Surgery, Center of Liver Transplantation
| | - Yong-gang Wei
- Department of Liver Surgery, Center of Liver Transplantation
| | - Bo Li
- Department of Liver Surgery, Center of Liver Transplantation
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Sparrelid E, Jonas E, Tzortzakakis A, Dahlén U, Murquist G, Brismar T, Axelsson R, Isaksson B. Dynamic Evaluation of Liver Volume and Function in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy. J Gastrointest Surg 2017; 21:967-974. [PMID: 28283924 PMCID: PMC5443865 DOI: 10.1007/s11605-017-3389-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite a fast and potent growth of the future liver remnant (FLR), patients operated with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are at risk of developing posthepatectomy liver failure. In this study, the relation between liver volume and function in ALPPS was studied using a multimodal assessment. METHODS Nine patients with colorectal liver metastases treated with neoadjuvant chemotherapy and operated with ALPPS were studied with hepatobiliary scintigraphy, computed tomography, indocyanine green clearance test, and serum liver function tests. A comparison between liver volume and function was conducted. RESULTS The preoperative FLR volume of 19.5% underestimated the preoperative FLR function of 25.3% (p = 0.011). The increase in FLR volume exceeded the increase in function at day 6 after stage 1 (FLR volume increase 56.7% versus FLR function increase 28.2%, p = 0.021), meaning that the increase in function was 50% of the increase in volume. After stage 2, functional increase exceeded the volume increase, resulting in similar values 28 days after stage 2. CONCLUSIONS In the inter-stage period of ALPPS, the high volume increase is not paralleled by a corresponding functional increase. This may in part explain the high morbidity and mortality rates associated with ALPPS. Functional assessment of the FLR is advised.
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Affiliation(s)
- Ernesto Sparrelid
- Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden.
| | - Eduard Jonas
- Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Division of Radiology, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Dahlén
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
| | - Gustav Murquist
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
| | - Torkel Brismar
- Division of Radiology, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Rimma Axelsson
- Division of Radiology, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Isaksson
- Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden
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50
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Zeile M, Bakal A, Volkmer JE, Stavrou GA, Dautel P, Hoeltje J, Stang A, Oldhafer KJ, Brüning R. Identification of cofactors influencing hypertrophy of the future liver remnant after portal vein embolization-the effect of collaterals on embolized liver volume. Br J Radiol 2016; 89:20160306. [PMID: 27730840 DOI: 10.1259/bjr.20160306] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The purpose of this retrospective study was to monitor hypertrophy of future liver remnant following portal vein embolization (PVE) before planned extended right hepatectomy. However, because individual responses to PVE are highly variable, our focus was to identify cofactors of successful hypertrophy. METHODS 28 patients with primary or secondary liver tumours, mean age 64.1 ± 12.9 years, underwent PVE. Volumetric analysis of hypertrophy before and after PVE (median 39.0 ± 15.7 days) was performed. The embolized liver segments were investigated for occurrence of reperfusion of their portal branches. Blood parameters before PVE were additionally investigated. RESULTS Patients were divided into responders (21/28) and non-responders (7/28) by post-PVE standardized future liver remnant being above or below 25%, respectively. No significant differences between the groups were found regarding biometric and volumetric parameters before PVE. In the entire group after PVE, the mean absolute increase of Segments 2 and 3 was 196.0 ± 84.7 cm3 and the median relative increase was 46.6 ± 98.8%. The formation of left to right hepatic portoportal collaterals exhibited a negative correlation to successful hypertrophy (p = 0.004) as well as low plasma total protein (p = 0.019). Successful embolization of Segment IV showed only a trend to significance (p = 0.098). CONCLUSION Cofactors associated with a favourable outcome regarding hypertrophy were the absence of collaterals in the control CT scans and high plasma total protein. Advances in knowledge: Portoportal collaterals negatively influence hypertrophy after PVE. On the other hand, plasma total protein is a positive prognostic indicator on hypertrophy of the liver in our cohort.
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Affiliation(s)
- Martin Zeile
- 1 Institute of Radiology and Neuroradiology, Asklepios Hospital Barmbek, Hamburg, Germany.,2 Semmelweis University, Medical Faculty, Campus Hamburg, Hamburg, Germany
| | - Artur Bakal
- 2 Semmelweis University, Medical Faculty, Campus Hamburg, Hamburg, Germany
| | - Jan E Volkmer
- 1 Institute of Radiology and Neuroradiology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Gregor A Stavrou
- 2 Semmelweis University, Medical Faculty, Campus Hamburg, Hamburg, Germany.,3 Department of Abdominal Surgery and Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Philip Dautel
- 2 Semmelweis University, Medical Faculty, Campus Hamburg, Hamburg, Germany.,4 Department of Gastroenterology and Interventional Endoscopy, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Jan Hoeltje
- 1 Institute of Radiology and Neuroradiology, Asklepios Hospital Barmbek, Hamburg, Germany.,2 Semmelweis University, Medical Faculty, Campus Hamburg, Hamburg, Germany
| | - Axel Stang
- 2 Semmelweis University, Medical Faculty, Campus Hamburg, Hamburg, Germany.,5 Department of Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Karl J Oldhafer
- 2 Semmelweis University, Medical Faculty, Campus Hamburg, Hamburg, Germany.,3 Department of Abdominal Surgery and Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Roland Brüning
- 1 Institute of Radiology and Neuroradiology, Asklepios Hospital Barmbek, Hamburg, Germany.,2 Semmelweis University, Medical Faculty, Campus Hamburg, Hamburg, Germany
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