Rescue ALPPS is efficient and safe after failed portal vein occlusion in patients with colorectal liver metastases

Ernesto Sparrelid,Lars Lundell,Torkel B Brismar,Bengt Isaksson,Stefan Gilg

doi:10.1007/s00423-016-1524-y

Ernesto Sparrelid, Lars Lundell + Show 3 more

Open Access

https://doi.org/10.1007/s00423-016-1524-y

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Abstract

PurposeThe aim of this study was to investigate whether associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can be used as an effective and safe rescue procedure in patients with colorectal liver metastases (CRLM) and insufficient effect on the future liver remnant (FLR) after previous portal vein occlusion (PVO).MethodsEleven patients with bilobar CRLM treated with neoadjuvant chemotherapy and previous PVO with insufficient effect on the FLR were analyzed retrospectively from a prospective database. FLR was evaluated with computed tomography volumetry 6 days after stage 1, and stage 2 was performed on day seven.ResultsSix days after stage 1, the median increase of the FLR was 209 ml (range 87–314, P < 0.001). This corresponded to a median FLR growth of 61.8 % (range 19.3–120) resulting in an FLR/BW ratio >0.5 % in all patients and successful subsequent removal of the tumor bearing liver (segments IV–VIII) in all patients with no 90-day mortality. No patient had a 3b-complication or more according to Clavien-Dindo. No patient developed severe posthepatectomy liver failure.ConclusionsThe powerful hypertrophy of the FLR associated with ALPPS seems to be maintained in patients with CRLM and previous failed PVO.

Highlights

Portal vein occlusion (PVO) by either selective embolization (PVE) or ligation (PVL) of the portal vein to the tumor bearing part of the liver is an established method to increase the size of the future liver remnant (FLR) [1, 2]
The powerful hypertrophy of the FLR associated with ALPPS seems to be maintained in patients with colorectal liver metastases (CRLM) and previous failed PVO
It has to be recalled that about one third of the patients submitted to PVO eventually never undergo a curative resection due to either insufficient growth of the FLR with an unacceptable risk of posthepatectomy liver failure (PHLF) if submitted to surgery, or they progress to an unresectable local tumor situation while awaiting the full PVO effect [4, 5]

Summary

Introduction

Portal vein occlusion (PVO) by either selective embolization (PVE) or ligation (PVL) of the portal vein to the tumor bearing part of the liver is an established method to increase the size of the future liver remnant (FLR) [1, 2]. The main purpose of this procedure is to convert previously unresectable patients to resection candidates by achieving sufficient size of the FLR before hepatectomy, in order to avoid posthepatectomy liver failure (PHLF) [3]. It has to be recalled that about one third of the patients submitted to PVO eventually never undergo a curative resection due to either insufficient growth of the FLR with an unacceptable risk of PHLF if submitted to surgery, or they progress to an unresectable local tumor situation while awaiting the full PVO effect [4, 5]. A recent review of the literature shows that the majority of the serious complications affect patients subjected to concomitant biliary surgery [6, 10, 11], while patients with colorectal liver metastases (CRLM) undergoing ALPPS seem to be less prone to develop high-grade complications [11].

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