Laparoscopic Alpps Procedure After Failed Portal Vein Embolization

Abstract

Presenter: Mathieu D'Hondt | Groeninge Hospital Kortrijk Background: Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) is a relatively new surgical technique for the resection of colorectal liver metastases (CRLMs) with insufficient future liver remnant (FLR). Only 27 cases of laparoscopic ALPPS have been reported in literature. This video aims to demonstrate our first experience with this minimally invasive approach. Methods: In January 2016 a 51 year old male patient presented with massive bilobar colorectal liver metastases. There was one CRLM in the left hemiliver and numerous CRLMs in the right hemiliver. The primary tumor was asymptomatic and the patient received 4 cycles of chemotherapy (Folfox/Panitumumab). Since the left hemiliver (=FLR) was only 16% of total liver volume (TLV) a right PVE (portal vein embolization) was performed. However, PVE failed and 4 weeks after PVE the FLR-volume was only 18% of TLV. Chemotherapy was continued till 12 cycles. The option of performing an ALPPS procedure was discussed with the patient and the patient agreed. First, a laparoscopic sigmoid resection was performed in October 2016. On December 12 2016 the first step of the ALPPS procedure was performed. During the first stage a metastasectomy in the left hemiliver was performed and the liver parenchyma between the left and right hemiliver was transected. Intraoperative ultrasound reveiled residual portal flow in the right hemiliver after PVE. The right portal vein was isolated an transected using a vascular stapler. Eight days postoperatively the volume of the left hemiliver was 30%. The second stage of ALPPS was performed 1 day later (9 days after the first stage). Results: Operative time of stage one was 300 minutes an blood loss was 150 ml. Postoperative course was uneventful and hospital stay was 4 days. Operative time of stage two was 90 minutes and blood loss was 150 ml. Postoperatively the patient developed grade A liver failure. The patient was discharged on postoperatieve day 8. At 20 months postoperatively there was no evidence of disease recurrence. Conclusion: Laparoscopic ALPPS appears to be feasable in experienced hands. The well-recognized advantages of laparoscopy may play a favorable role in the management of patients with bilobar CRLMs candidate for an ALPPS procedure.