Fast-track two-stage hepatectomy using hybrid radiology/operating room suite as alternative option to ALPPS procedure

Abstract

Background: Colorectal liver metastasis (CLM) with bilateral distribution can be managed by two-stage hepatectomy (TSH), however the timeline between the two stages can be concerning for potential drop-out and failure to complete TSH. We present the concept of fast-track TSH (FT-TSH) with first-stage hepatectomy and portal vein embolization (PVE) simultaneously performed in a hybrid interventional radiology/operating room suite (hybrid IR/OR). Methods: Following preoperative chemotherapy, a 38 year-old female patient with bilobar CLM underwent first-stage resection of four left-sided liver lesions immediately followed by a right-sided percutaneous PVE, in collaboration with interventional radiology, using a hybrid IR/OR. Results: First-stage hepatecomy and right PVE were performed without any complications with a total combined operating time of 3.5 hours. Subsequent future liver remnant (FLR) volumetry 28 days after combined first-stage hepatectomy + right PVE procedures demonstrated adequate hypertrophy with a post-PVE FLR of 46.5% of the total estimated total liver volume (kinetic growth rate: 3.2% per week). Patient underwent completion TSH with a right hepatectomy 33 days following the first-stage procedure. There was no perioperative morbidity. Conclusion: Fast-track two-stage hepatectomy is an efficient strategy to reduce time between stages, number of hospital encounters, and allows early return to intended oncologic treatment. It provides an alternative to ALPPS procedure in patients with advanced bilateral liver metastases.