Total Laparoscopic Reversal ALPPS (original) (raw)
Related papers
International Journal of Surgery, 2014
Background: Partial hepatectomy with clear surgical margins is the main curative treatment for hepatic malignancies. The safety of liver resection, to a great extent, depends on the volume of future liver remnant. This manuscript reviews some important strategies that have been developed to increase resectability for patients with borderline volume of future liver remnant, particularly associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Methods: To identify potentially relevant articles, we searched Medline and PubMed from January 2010 to December 2013 using the keywords "Associating liver partition and portal vein ligation for staged hepatectomy", "ALPPS", "portal vein embolization", "future liver remnant", "liver hypertrophy", and "liver failure". A number of references from the key articles were also cited. There were no exclusion criteria for published information to the topics. Results: Portal vein ligation (PVL) or embolization (PVE) are traditional approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, about 14 percent of patients fail to this approach. Adequate hypertrophy of the FLR using PVL or PVE generally takes more than four weeks. ALPPS can induce rapid growth of the FLR, which is more effective than by portal vein embolization or occlusion alone. Reportedly, the hypertrophy extent of FLR was 40%e80% within 6e9 days in contrast to approximately 8%e27% within 2e60 days by PVL/PVE. However, ALPPS was reported to have high operative morbidity (16%e64% of patients), mortality (12% e23% of patients) and bile leakage rates. Bile leakage and sepsis remain a major cause of morbidity, and the main cause of mortality includes hepatic insufficiency. Conclusion: ALPPS has emerged as a new strategy to increase resectability of hepatic malignancies. Due to high morbidity and mortality rates of ALPPS procedure, the surgical candidates should be selected carefully. Moreover, there are very limited available evidence for its technical feasibility, safety and oncological outcome which are needed for further evaluation in larger scale of studies.
Laparoscopic Liver Partition and Portal Vein Ligation for Staged Hepatectomy
CRSLS: MIS Case Reports from SLS, 2014
Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been introduced as a feasible strategy that allows complete resection with curative intention in selected patients with otherwise locally unresectable disease due to an insufficient future liver remnant. Minimally invasive surgery has shown several benefits over the open approach in different surgical areas, including liver resections, over the past 2 decades. We report a case of a pure laparoscopic ALPPS. Case Description: A 73-year-old woman with a single hepatic metastasis from breast cancer was referred to our unit. She had been treated with radical left and right mastectomy 30 and 15 years before referral. Magnetic resonance imaging and positron emission tomographic computed tomography demonstrated a single hypermetabolic 68-mm tumor mass located in the right liver lobe without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled, but due to unexpected tumor extension during surgical exploration and the need for a larger than planned liver resection, a pure laparoscopic ALPPS approach was performed. After a 41% future liver remnant hypertrophy, the patient underwent a laparoscopic completion surgery without any complications. She had a favorable recovery and was discharged on postoperative day 3. The histopathological analysis indicated multiple metastatic breast cancer with negative resection margins. Discussion and Conclusions: Pure laparoscopic ALPPS is feasible and may be performed safely in experienced hands. Minimally invasive access may represent a good alternative to reduce the surgical impact of the ALPPS approach in terms of postoperative recovery in selected patients.
Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS): Tips and Tricks
Journal of Gastrointestinal Surgery, 2013
Background Posthepatectomy liver failure is the most severe complication after major hepatectomies and it is associated with an insufficient future liver remnant (FLR). Associating liver partition and portal vein ligation (PVL) has recently been described as a revolutionary strategy to induce a rapid and large FLR volume increase. We aim to describe our surgical technique, patient management, and preliminary results with this new two-stage approach. Technique During the first stage, liver partition and PVL of the diseased hemiliver are performed. The completion surgery is carried out after volumetric studies have demonstrated a sufficient FLR and provided the patient is in good condition. This is usually achieved after 7 days. In the second step, the patient undergoes a completion surgery with right hepatectomy, right trisectionectomy, or left trisectionectomy. Results Fifteen patients with advanced liver tumors were treated. Nine patients were males and the mean age was 54 years old. The mean difference between the preoperative and postoperative FLR volume was 303 ml (p<0.001), which represented a mean volume increase of 78.4 %. All resections were R0. Morbidity and mortality rates were 53 and 0 %, respectively. The average hospital stay was 19 days. Conclusions The presented technique was feasible and safe in the hands of experienced hepatobiliary surgeons, with satisfactory short-term results. It induces rapid liver hypertrophy and at the same time it offers the possibility of cure to patients previously declared unresectable.
The American journal of case reports, 2016
Unusual clinical course Background: Associated Liver Partition and Portal vein ligation with Staged hepatectomy (ALPPS) leads to rapid hepatic hypertrophy and decreases incidence of post-hepatectomy liver failure in patients with a marginal future liver remnant. Various procedural ALPPS modifications were previously described. Here, we present the first case of a new ALPPS modification, carrying out a left hepatic trisectionectomy with segment 1. Case Report: We present the case of a 36-year-old woman with locally advanced sigmoid adeno-carcinoma and extensive left liver metastases extending to segment V and VIII, who received state-of-the-art systemic conversion chemotherapy. Preoperative CT volumetric scan demonstrated a FLR/TLV (Future Liver Remnant/Total Liver Volume) of 22%. A left hepatic trisectionectomy procedure was conducted using our new ALPPS modification. Sufficient hepatic hypertrophy of FLR was reached with a volume increase of 100%. The period between the 2 stages was 7 days. The patient underwent left trisectionectomy and left colectomy with tumor-free margins. All dissected lymph nodes were tumor-negative. The surgical intra-and postoperative course was uneventful. Medically, the patient acquired an Acinetobacter infection, with severe sepsis and acute renal injury. After 3 dialysis sessions, the renal function recovered completely. Afterwards, the patient recovered slowly, and reintroduction ambulation and oral feeding was prolonged. Later on, the patient received Xeloda 1500 mg twice daily as adjuvant chemotherapy. Conclusions: The new ALPPS modification leads to a sufficient hypertrophy of FRL within 1 week, allowing left hepatic trisectionectomy with tumor-free FRL. Despite the challenging complications, the new ALPPS modification might represent an alternative procedure for use when the classic ALPPS procedure is not applicable. Further studies are required.
Canadian Journal of Surgery, 2017
Background: Early reports of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) outcomes have been suboptimal. The literature has confirmed that learning curves influence surgical outcomes. We have 54 months of continuous experience performing ALPPS with strict selection criteria. This study aimed to evaluate the impact of the learning curve on ALPPS outcomes. Methods: We retrospectively compared patients who underwent ALPPS between April 2012 and March 2016. Patients were grouped into 2 24-month (early and late) periods. All candidates had a high tumour load requiring staged hepatectomy after chemotherapy response, a predicted future liver remnant (FLR) less than 30% and good performance status. Results: Thirty-three patients underwent ALPPS during the study period: 16 in the early group (median age 65 yr, mean body mass index [BMI] 27) and 17 in the late group (median age 60 yr, mean BMI 25). Bilobar disease was comparable in both groups (94% v. 88%, p > 0.99). Duration of surgery was not statistically different. Intraoperative blood loss and need for transfusion were significantly lower in the late group (200 ± 109 mL v. 100 ± 43 mL, p < 0.05). The late group had a higher proportion of monosegment ALPPS (4:1). There were no deaths within 90 days in either cohort. Rates of postoperative complications were not statistically significant between groups. The R0 resection rate was similar. The entire 1-year disease-free and overall survival were 52% and 84%, respectively. Conclusion: Excellent results can be obtained in innovative complex surgery with careful patient selection and good technical skills. Additionally, the learning curve brought confidence to perform more complex procedures while maintaining good outcomes. Contexte : Les premiers résultats sur l'association de la partition hépatique et de la ligature portale pour l'hépatectomie en 2 temps (ALPPS) sont sous-optimaux. La littérature a confirmé que les courbes d'apprentissage influencent les résultats des interventions chirurgicales. Notre étude reposait sur 54 mois consécutifs d'utilisation de la technique ALPPS selon des critères de sélection rigoureux. Elle visait à évaluer l'effet de la courbe d'apprentissage sur les résultats liés à l'ALPPS. Méthodes : Nous avons procédé à une comparaison rétrospective des patients traités par l'ALPPS entre avril 2012 et mars 2016. Nous avons divisé les patients en 2 groupes de 24 mois (précoce et tardif). Tous les candidats avaient une charge tumorale élevée nécessitant une hépatectomie en 2 temps après une réponse à la chimiothérapie, un volume estimé de futur foie résiduel (FFR) inférieur à 30 % et un indice fonctionnel favorable. Résultats : Trente-trois patients ont été traités par l'ALPPS pendant la période de l'étude : 16 dans le groupe précoce (âge médian 65 ans, indice de masse corporelle [IMC] moyen 27) et 17 dans le groupe tardif (âge médian 60 ans, IMC moyen 25). Le taux de maladie bilobaire était comparable entre les 2 groupes (94 % c. 88 %, p > 0,99). La durée de la chirurgie n'était pas statistiquement différente. Les pertes de sang peropératoires et le besoin de transfusion étaient significativement inférieurs dans le groupe tardif (200 ± 109 mL c. 100 ± 43 mL, p < 0,05). Le groupe tardif avait une proportion plus élevée d'ALPPS mono-segmentaires (4:1). Il n'y a eu aucun décès dans les 90 jours parmi les 2 cohortes. Les taux de complications postopératoires n'étaient pas statistiquement significatifs entre les groupes. Le taux de résection R0 était similaire. Les taux de survie sans récidive après une année complète et de survie globale étaient de 52 % et de 84 %, respectivement.
ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review
PloS one, 2015
To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature. Since January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Until July 2014 ALPPS was completed in 9 patients whose mean age was 60±8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289±122 mL (21.1±5.5%) before ALPPS-1 and 528±121 mL (32.2±5.7%) before ALLPS-2 (p<0.001). The increase in FLR between the two proce...
BACKGROUND: Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. To induce rapid and significant hepatic hypertrophy, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients which tumor is previously considered unresectable. AIM: To present the Brazilian experience with ALPPS approach. METHOD: Were analyzed 39 patients who underwent hepatic resection using ALPPS in nine hospitals. The procedure was performed in two steps. The first operation was portal vein ligation and in situ splitting. In the second operation the right hepatic artery, right bile duct and the right hepatic vein were isolated and ligated. The extended right lobe was removed. There were 22 male (56.4%) and 17 female (43.6%). At the time of the first operation, the median age was 57.3 years (range: 20-83 years). RESULTS: The most common indication was ...
Associating Liver Partition and Portal Vein Ligation forStaged Hepatectomy in 2020
2020
Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) is proposed as a surgical option for the patients with no other surgical option with failed portal vein embolization or extremely small future liver remnant. Since the first publication of the technique in 2012, this technique evolved nowadays to partial ALPPS and minimal-invasive ALPPS. Conventional two-stage hepatectomy remains a feasible option for older patients and those with a liver to body-weight-ratio of > 0,4.