Increase In Future Liver Remnant Research Articles

Pure Laparoscopic Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) for a Giant Hepatocellular Carcinoma (> 15 cm) Abutting the Liver Hilum

IntroductionThis video manuscript presents a unique case of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure performed in case of a giant hepatocellular carcinoma (> 15 cm in size) whereby both stages were completed via the pure laparoscopic approach. MethodsThis case was performed in our institution in 2022. All data were obtained from the patient’s records in our prospectively maintained database. Institutional Review Board (IRB) was not required for this publication. ResultsA 67-year-old Chinese male with a history of chronic hepatitis B infection presented with a giant liver mass. Magnetic resonance imaging (MRI) scan demonstrated a tumour, with features compatible with hepatocellular carcinoma, measuring 15.4 cm in maximal diameter in the right lobe of the cirrhotic liver with no distal metastasis. The indocyanine green (ICG) retention test at 15 min was prolonged at 25.5%, and the CT volumetry showed a borderline future liver remnant (FLR) volume of 692 ml or 22.9% (based on measured volume) and a standardized FLR of 49%. Stage 1 ALPPS was successfully completed via the pure laparoscopic approach. He was well post-operatively, and a repeat CT volumetry at 7 days showed an increase in FLR to 826 ml, and the ICG retention test improved to 18.1%. The patient underwent pure laparoscopic second-stage ALPPS, 8 days later. The patient recovered well with no liver decompensation or local complications. ConclusionThe use of MIS for in 2-stage ALPPS procedure for giant HCCs larger than 10 cm is technically feasible and safe when attempted in high-volume centres by experienced surgeons, while benefiting from the advantages of MIS liver resection.

Study of ultrasound-guided percutaneous microwave ablation combined with portal vein embolization for rapid future liver remnant increase of planned hepatectomy.

To evaluate the efficacy of ultrasound-guided percutaneous microwave ablation (PMA) combined with portal vein embolization (PVE) for planned hepatectomy. We retrospectively reviewed data of 18 patients with multiple right liver tumors or hilar tumor of liver invades the surrounding tissue and insufficient future liver remnant (FLR) for hepatectomy from July 2015 to March 2017. Ultrasound-guided PMA was performed by using PMCT cold circulation microwave treatment apparatus. PVE was performed after PMA. The increase of FLR was evaluated by computed tomography (CT) 6-22 days after PVE. The proportion of FLR, increase in the amplitude of FLR, procedure-related complications, perioperative morbidity and mortality, and overall survival (OS) rates, the median survival time were analyzed. The median volume of FLR before PMA and PVE was 369.7ml (range: 239.4-493.1ml). After a median waiting period of 11.5 days (range: 6-22 days), the median volume of FLR was increased to 523.4ml (range: 355.4-833.3ml). The changes in FLR before and after PMA and PVE were statistically significant (p<0.001). No serious perioperative complications or mortality were found. After a median follow-up time of 51.0 months (range: 2-54 months), the 6-month, 1-year, 2-year, 3-year and 4-year survival rates were 88.9%, 72.2%, 44.4%, 33.3%, 22.2%, respectively, and the median survival time was 15.0 ± 7.1 months. PMA combined with PVE increases FLR rapidly, avoids touching malignant tumors, and produces fewer procedure-related complications. It appears safe and efficacious for planned hepatectomy.

Application of associating liver partition and portal vein ligation for staged hepatectomy for initially unresectable hepatocellular carcinoma

ObjectiveTo evaluate the safety and efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in the treatment of initially unresectable hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and to preliminarily explore the mechanism of rapid growth of the future liver remnant (FLR).MethodsTwenty-four patients with HBV-associated HCC who underwent ALPPS in our hospital from August 2014 to January 2021 were retrospectively studied. Propensity score matching was used to compare oncologic outcomes of patients treated with ALPPS and transarterial chemoembolization (TACE). The expression of YAP and JNK in liver tissue after two stages of ALPPS were detected.ResultsThe median standard liver volume (SLV) was 1471.4 ml. Before second stage of ALPPS, the median FLR increased by 74.4%, and the median FLR/SLV increased from 26.1 to 41.6%. Twenty-two patients (91.7%) received staged hepatectomy after a median interval of 15 (9–24) d. The total incidence of postoperative complications in ALPPS group was 54.5%, and of Clavien–Dindo ≥ IIIb postoperative complications (requiring surgical, endoscopic or radiological intervention under general anesthesia) was 9.1%. There was no significant difference in total complications between ALPPS group and TACE group, but there were lower rate of above grade III complications in the TACE group than that in the ALPPS group. The incidence of complications was lower in laparoscopic-ALPPS than that in open surgery. In ALPPS group, the 1-year, 2-year and 5-year overall survival rate were respectively 71.4%, 33.3% and 4.8%. Interval time was an independent risk factor associated with overall survival rate. There was no significant difference in overall survival rate between ALPPS group and TACE group. For advanced HCC (BCLC stage B and C), ALPPS group was not superior to TACE group in overall survival rate. The expression of YAP and p-JNK in the residual liver tissue after second stage procedure was higher than that after first stage procedure, and the co-expression of YAP and p-JNK was observed in the residual liver tissue.ConclusionALPPS is a safe and effective treatment for initially unresectable HBV-associated HCC. Laparoscopic technique might improve the effect of ALPPS. YAP and JNK pathway might take a role in rapid FLR increase in ALPPS procedure.

Rescue percutaneous transhepatic portal vein embolization after failed associated liver partition and portal vein ligation for staged hepatectomy in a patient with multiple liver metastases of rectal cancer: a case report

BackgroundLiver metastasis is the most common form of distant spread of colorectal cancer. Despite oncological and surgical advances, only about 25% of patients are eligible to undergo resection. As the liver has a limited resectable volume, tumor reduction and remnant liver hypertrophy are of critical importance in treating initially unresectable colorectal cancer liver metastasis. Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows rapid liver hypertrophy within a short period and has been reported to be useful in recent years.Case presentationA 29-year-old woman complaining of bloody stool was referred to our hospital. She was diagnosed with rectal cancer (Rb) with simultaneous multiple liver and lung metastases. The patient was then initially commenced on chemotherapy and completed it with a satisfactory response. Right trisectionectomy was necessary to achieve hepatic clearance; however, the future liver remnant (FLR) volume was insufficient. Therefore, we decided to perform totally laparoscopic ALPPS to obtain enough FLR volume. However, the FLR increase was slow, and FLR did not attain the required volume for right trisectionectomy. Computed tomography showed that right portal venous blood flow was increased via developed collateral vessels around the portal vein. We attempted to induce further liver growth by blocking portal blood flow using additional percutaneous transhepatic portal vein embolization (PTPE), and a rapid increase in FLR was obtained. The patient underwent right trisectionectomy and partial resection of S2 with negative margins, and the patient was discharged without postoperative liver failure.ConclusionsResumption of the portal venous blood flow through collateral vessels after ALPPS may have interfered with the planned residual liver hypertrophy. Performing PTPE in addition to ALPPS increased the FLR volume, and radical hepatectomy was completed safely. Remnant portal venous blood flow following ALPPS is an important issue to be considered in surgical planning, and early additional portal vein embolization could be effective.

Evidence on Indications and Techniques to Increase the Future Liver Remnant in Children Undergoing Extended Hepatectomy: A Systematic Review and Meta-Analysis of Individual Patient Data

BackgroundTechniques to increase the future liver remnant (FLR) have fundamentally changed the indications and criteria of resectability in adult liver surgery. In pediatric patients however, these procedures have rarely been applied and the potential benefit or harm as well as suited indications are unclear.MethodsA systematic literature search of MEDLINE, Web of Science, and CENTRAL was conducted. Based on a PRISMA-compliant, predefined methodology, all studies reporting pediatric patients (< 18y) undergoing liver resection with either associating liver partition and portal vein ligation for stages hepatectomy (ALPPS) or preoperative portal vein embolization or ligation (PVE/PVL) were included. Baseline data, periinterventional morbidity, increase of FLR and outcomes were analyzed.Results15 studies reporting on 21 pediatric patients with a mean age of 4 years and 7 months (range 1.8 months – 17 years) were included. 12 ALPPS procedures, 8 PVE and 1 PVL were performed. The applied criteria for performing ALPPS or PVE were heterogenous and thresholds for minimally acceptable FLR varied. Mean FLR [% of total liver volume] before the intervention was 23.6% (range 15.0 – 39.3%) in the ALPPS group and 31.4% (range 21.5 – 56.0%) in the PVE group. Mean increase of FLR before stage 2 resection was 69.4% (range 19.0 – 103.8%) for ALPPS and 62.8% (range 25.0 – 108.0%) after PVE. No postoperative death occurred, one early intrahepatic recurrence after an ALPPS procedure was reported. Overall postoperative morbidity was 23.8%.ConclusionValidated criteria for minimal FLR in pediatric liver resection are lacking and so are clear indications for ALPPS or PVE. In special cases, ALPPS and PVE can be valuable techniques to achieve complete resection of pediatric liver tumors. However, more data are needed, and future studies should focus on a definition and validation of posthepatectomy liver failure as well as the minimally needed FLR in pediatric patients undergoing extended hepatectomy.Systematic Review Registration[www.clinicaltrials.gov], identifier [PROSPERO 2021 CRD42021274848].

Neoadjuvant Hemi-Liver Directed Selective Internal Radiation Therapy (SIRT) Followed by Portal Vein and Liver Vein Embolization Could Make Non-Operable Patients with Liver Cancer Eligible for Curative Intended Major Liver Resection

Introduction: The majority of patients with liver cancer is non-operable due to high tumor burden and/or impaired liver function with low regenerative potential of the liver tissue. Selective internal radiation therapy (SIRT) applicated to one liver lobe can control the liver cancer there, buy time for hypertrophy and induce hypertrophy in the contra-lateral future liver remnant (FLR). Still hypertrophy could be insufficient for liver resection. Portal vein embolization (PVE) combined with liver vein embolization (LVE) boost liver hypertrophy and patients could become eligible for curative intended major liver resections. Aim of the multi-center European SIR Spheres Surgical Registry (ESSURE) is to evaluate if the concept of hemi-liver SIRT followed by liver resection is feasible for patients that were initially non-operable. Methods: First data analysis of patients enrolled to ESSURE Results: 14 patients were recruited (9 HCC in cirrhosis, 1HCC without cirrhosis, 2 iCCC with fibrosis,1 CRLM,1 NET). All received successful SIRT to the right liver lobe without major complications. SIRT dose was 1.4-2.4 Gbq. 5 patients received additional PVE & LVE to the right liver lobe. The increase of future liver remnant after SIRT was 22%, after additional PVE & LVE 34%. Finally in 5/14 (36%) patients major liver resection could be performed (3 HCC,2 iCCC). 1 patient died, the other 4 patients showed an uncomplicated post-operative course (no complications >3a Clavien-Dindo). Conclusion: Neoadjuvant hemi-Liver SIRT followed by portal vein and liver vein embolization seems feasible and could make selected, initially non-operable patients eligible for curative intended liver resection.

Increase of Liver Function and Volume after ALPPS Determined by MRI in a Rat Model

Introduction: It has been hypothesized that rapid increase of liver volume after ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) is not accompanied by a proportional increase of function. This study uses a rat models of major liver resection (LR), ALPPS and portal vein ligation (PVL) to test this hypothesis by measuring liver volume and function with contrast-enhanced magnetic resonance imaging (MRI). Methods: Wistar rats (200-250g) were randomly allocated to LR, ALPPS or PVL. T1-weighted MRI scans (7.0T MR Solutions,Guildford,UK) were performed until postoperative day 5. Uptake kinetics (2D-FLASH;TR/TE=589/8) of Primovist® (1mmol/kg,Bayer AG,Berlin, Germany) were measured in the future liver remnant (FLR) and spleen (blood pool). Liver volume was assessed during the excretion phase (2D-FLASH;TR/TE=4150/11; thickness 1mm). Liver function of the FLR was defined as the inverse value of time [min] from injection of Primovist® to maximum signal intensity multiplied by respective volume of the FLR [ccm]. Results: Percent increase of FLR volume overestimates FLR function at day 1 in all three, ALPPS, LR and PVL. From day 2, function and volume of the FLR increase proportionally in all procedures (Figure 1). Percent increase of liver function exceeds liver volume from day 2 until day 5 in ALPPS and LR, but not in PVL. Conclusion: This animal study rejects the hypothesis that functional increase is not proportional to volume increase in ALPPS. While function is impaired on day 1, ALPPS leads to a congruent increase of volume and function after day 1, similar to LR.

Ipsilateral access portal venous embolization (PVE) for preoperative hypertrophy exhibits low complication rates in Clavien-Dindo and CIRSE scales

BackgroundPortal venous embolization (PVE) is a minimal invasive preoperative strategy that aims to increase future liver remnant (FLR) in order to facilitate extended hemihepatectomy. We analyzed our data retrospectively regarding complications and degree of hypertrophy (DH).Methods: 88 patients received PVE either by particles / coils (n = 77) or by glue / oil (n = 11), supported by 7 right hepatic vein embolizations (HVE) by coils or occluders. All complications were categorized by the Clavien- Dindo (CD) and the CIRSE classification.ResultsIn 88 patients (median age 68 years) there was one intervention with a biliary leak and subsequent drainage (complication grade 3 CD, CIRSE 3), two with prolonged hospital stay (grade 2 CD, grade 3 CIRSE) and 13 complications grade 1 CD, but no complications of grade 4 or higher neither in Clavien- Dindo nor in CIRSE classification. The median relative increase in FLR was 47% (SD 35%). The mean pre-intervention standardized FLR rose from 23% (SD 10%) to a post-intervention standardized FLR of 32% (SD 12%). The degree of hypertrophy (DH) was 9,3% (SD 5,2%) and the kinetic growth rate (KGR) per week was 2,06 (SD 1,84).ConclusionPVE and, if necessary, additional sequential HVE were safe procedures with a low rate of complications and facilitated sufficient preoperative hypertrophy of the future liver remnant.

3D voxel-based dosimetry to predict contralateral hypertrophy and an adequate future liver remnant after lobar radioembolization

Volume changes induced by selective internal radiation therapy (SIRT) may increase the possibility of tumor resection in patients with insufficient future liver remnant (FLR). The aim was to identify dosimetric and clinical parameters associated with contralateral hepatic hypertrophy after lobar/extended lobar SIRT with 90Y-resin microspheres. Patients underwent 90Y PET/CT after lobar or extended lobar (right + segment IV) SIRT. 90Y voxel dosimetry was retrospectively performed (PLANET Dose; DOSIsoft SA). Mean absorbed doses to tumoral/non-tumoral-treated volumes (NTL) and dose-volume histograms were extracted. Clinical variables were collected. Patients were stratified by FLR at baseline (T0-FLR): < 30% (would require hypertrophy) and ≥ 30%. Changes in volume of the treated, non-treated liver, and FLR were calculated at < 2 (T1), 2-5 (T2), and 6-12months (T3) post-SIRT. Univariable and multivariable regression analyses were performed to identify predictors of atrophy, hypertrophy, and increase in FLR. The best cut-off value to predict an increase of FLR to ≥ 40% was defined using ROC analysis. Fifty-six patients were studied; most had primary liver tumors (71.4%), 40.4% had cirrhosis, and 39.3% had been previously treated with chemotherapy. FLR in patients with T0-FLR < 30% increased progressively (T0: 25.2%; T1: 32.7%; T2: 38.1%; T3: 44.7%). No dosimetric parameter predicted atrophy. Both NTL-Dmean and NTL-V30 (fraction of NTL exposed to ≥ 30Gy) were predictive of increase in FLR in patients with T0 FLR < 30%, the latter also in the total cohort of patients. Hypertrophy was not significantly associated with tumor dose or tumor size. When ≥ 49% of NTL received ≥ 30Gy, FLR increased to ≥ 40% (accuracy: 76.4% in all patients and 80.95% in T0-FLR < 30% patients). NTL-Dmean and NTL exposed to ≥ 30Gy (NTL-V30) were most significantly associated with increase in FLR (particularly among patients with T0-FLR < 30%). When half of NTL received ≥ 30Gy, FLR increased to ≥ 40%, with higher accuracy among patients with T0-FLR < 30%.

The Most Minimally-invasive ALPPS - Using Terminal Branches Portal Vein Embolization (TBPVE) for Liver Partition (A Report of 24 Cases)

Introduction: Numerous modifications have been suggested for improvement of ALPPS. We suggest Terminal Branches Portal Vein Embolization (TBPVE) as a minimally-invasive way to partition the liver. The intra-hepatic portal vein communication can thus be blocked between both liver. As a result, only a single surgical operation is required. This method is termed Terminal branches portal vein Embolization Liver Partition Planned hepatectomy (TELPP). Methods: From February 2016 to November 2017, 24 patients were performed with TELPP. The procedure was that in addition to PVE, embolization agent was infused to the terminal branches of portal vein of S5, S8 or S4. In order to avoid potential enlargement of tumor, in some cases tumor TACE were used at the same time. Standard liver volume(SLV), future liver remnant (FLR) and FLR/SLV are calculated by CT scan taken. Open or laparoscopic hepatectomy was performed in two weeks when the FLR is appropriate. Results: All the patients (most of the liver were cirrhotic;4 patients with PVTT) achieved enough FLR that had a median increase of 55.6% (from 26.2% to 120.8%) in two weeks. All of them underwent hepatectomy, most of them were extended hemihepatectomy and trisegmentectomy. No server morbidity occurred except 1 case with minor ectopic thrombus. 3 patients died respectively 15,18,7 months, all the other 21 patients are surviving. Conclusion: This study shows that TBPVE had a rapid FLR increase similar to ALPPS without it's drawback. TELPP is very promising, cause requiring only one single operation instead of two staged operations.

Clinical evaluation of modified ALPPS procedures based on risk-reduced strategy for staged hepatectomy

Introduction and ObjectivesRadical resection remains the only curative treatment for liver tumors. Although associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can increase the resection rate, huge controversy exists for high reported mortality and morbidity. This study was to evaluate the efficacy and safety of modified ALPPS procedure. Patients and MethodsPatients who were performed ALPPS in single-center in recent 5 years were retrospectively reviewed. The modified strategy included strict patient selection, precise future liver remnant (FLR) assessment and operation planning, and usage of minimally invasive methods. Data including clinical records, functional FLR increase, complications, and overall survival (OS) were analyzed. ResultsSixty patients underwent modified ALPPS procedure and recovered well. No severe complications happened after the 1-stage operation, and the increasing FLR was 179.3 cm3(±72.4 cm3), with similar functional FLR increase. The OS was 20.0 months (±4.5month). ConclusionsALPPS could be a feasible treatment for complex liver tumors by risk-reduced modification. It could be expected to provide long-term survival for patients without enough FLR.

Percutaneous Portal Vein Embolization Using a Simplified Sheathless 18-Gauge Trocar Needle Approach: Review of Efficacy and Safety

PurposePortal vein (PV) embolization (PVE) is traditionally performed via a PV sheath with selective embolization of PV branches. Here, the efficacy and safety of PVE with the use of only an 18-gauge needle is reported. Materials and MethodsConsecutive patients who underwent PVE from 2009 through 2017 were retrospectively reviewed. Forty-five patients (mean age, 60 y ± 7.6; 38 men) underwent 45 PVE procedures. Hepatocellular carcinoma, cholangiocarcinoma, and metastases accounted for 26 (58%), 13 (29%), and 6 (13%) patients, respectively. PVE was performed by puncturing a branch of right PV with an 18-gauge needle under US guidance. Via the same needle, direct portography was performed, followed by PVE with an N-butyl cyanoacrylate/Lipiodol mixture. Percentage increase of future liver remnant (FLR) volume and increase in ratio of FLR to total liver volume were estimated as measures of efficacy. Complications were reported according to Society of Interventional Radiology classification. Fluoroscopy time, procedure time, and dose–area product (DAP) were recorded. ResultsTechnical success rate was 100%. The median DAP, fluoroscopy time, and procedure time were 74,387 mGy·cm2 (IQR, 90,349 mGy·cm2), 3.5 min (IQR, 2.10 min), and 24 min (IQR, 10.5 min). Among the 23 patients with complete CT volumetry data, mean increase in the ratio of FLR to total liver volume and percentage increase of FLR volume were 12.5% ± 7.7 and 50% ± 33, respectively. There were 3 minor complications (asymptomatic nonocclusive emboli in FLR) and 3 major complications (1 hepatic vein emboli, 1 subphrenic collection, and 1 hepatic infarct). ConclusionsPVE via a sheathless 18-gauge needle approach is feasible, with satisfactory FLR hypertrophy.

Effect of Hyperbilirubinemia on Hepatic Hypertrophy after Portal Vein Embolization and Liver Failure after Hepatectomy in Primary Biliary Malignancy

PurposeTo retrospectively investigate the impact of hyperbilirubinemia on future liver remnant (FLR) volume after percutaneous transhepatic portal vein embolization (PVE) and incidence of post-hepatectomy liver failure in primary biliary malignancy. Materials and MethodsEighty-seven patients (62 men, overall mean age 66.9 y) who underwent PVE, using Gelfoam and coils before major hepatectomy between January 2004 and June 2016, were included in this study and divided into a hyperbilirubinemia (serum total bilirubin level at PVE 5.80 ± 2.44 mg/dL; n = 41) group and a control group (1.09 ± 0.73 mg/dL; n = 46). Liver volume was measured from computerized tomographic data before and 18.5 days, on average, after PVE. Correlation between FLR hypertrophy (degree of hypertrophy and percentage increase in future liver remnant [%FLR]) and total bilirubin were analyzed. FLR hypertrophy and incidence of post-hepatectomy liver failure were compared. Simple and multiple regressions were used for univariable and multivariable analyses, respectively. ResultsMean FLR volumes before and after PVE were 529.1 cm3 and 640.5 cm3, respectively. Degree of hypertrophy and %FLR were 7.64 ± 4.22 and 21.77 ± 13.34, respectively. There was no significant correlation between FLR hypertrophy and total bilirubin (P > .5). FLR hypertrophy was not significantly different between the 2 groups. Planned major hepatectomy was performed in 73 patients (83.9%). Grade 3 post-hepatectomy liver failure occurred in 6 patients (8.2%; 2 in the hyperbilirubinemia group and 4 in the control group), and its incidence was not significantly different between the groups (P = .354). ConclusionsHyperbilirubinemia at the time of PVE seems to have no effect on FLR hypertrophy. The incidence of grade 3 post-hepatectomy liver failure is not likely to be influenced, either.

The ALPPS procedure: hepatocellular carcinoma as a main indication. An Italian single-center experience.

The ALPPS is a technique that allows achieving hepatic resection by a rapid future liver remnant hypertrophy. The aim of this study was to report the experience of an Italian center with ALPPS in patients with liver tumors. A retrospective analysis of patients undergoing ALPPS between 2012 and 2017 was performed. Patients' characteristics and disease presentation, increase in future liver remnant (FLR) as well as intraoperative and postoperative short- and long-term outcomes were evaluated. A total of 24 patients underwent the ALPPS procedure: 17 procedures for hepatocarcinoma (HCC), 5 for colorectal liver metastases (CRLM), 1 for cholangiocarcinoma (CC) and 1 for Merkel Cell Carcinoma liver metastasis (MCCLM). Macrovascular invasion (MVI) was recorded in 10 (41.6%) patients: 8 (33.3%) patients with HCC had invasion of portal vein (5), middle hepatic vein (2) and inferior vena cava (1). One patient with CRLM had involvement of middle hepatic vein and one patient with CC had involvement of right portal vein and middle hepatic vein. A p-ALPPS in 14 cases (58.3%), 10 t-ALPPS (41.6%) and hanging maneuver in 19 patients (80%) were performed. Median postoperative stay was 26days (range 16-68days). 90-day mortality was 8.3% (two patients, one with CC and one with HCC), 90-day mortality for HCC was 5.8%. After stage 1, we counted 15 complications all of grade I; after stage 2 the number of complications was increased to 37:33 were of grade I and 4 were of grade IV. R0 resection was achieved in all patients with 100% oncology feasibility. After a median follow-up of 10months (range 2-54), disease recurrence has been recorded in 6 patients with HCC and in 2 with CRLM. Eleven patients died, nine affected by HCC, one by CRLM, and one by CC. 2-years OS and disease-free survival (DFS) for the entire group were 47.3% and 47.5%, respectively. Concerning patients operated on for HCC, the 2-years OS and DFS were 38.5% and 60%, respectively. The ALPPS procedure is an interesting approach for large primary or secondary liver tumor with small FLR above all for large HCC associated with MVI, with acceptable OS and DFS.

Utility of portal vein embolization in surgical management of locally advanced gallbladder cancer

Introduction: Portal vein embolization (PVE) enables surgical resection of hepatobiliary tumours which would otherwise be unresectable due to insufficient future liver remnant (FLR). Here, we evaluated the outcomes after PVE for carcinoma gallbladder (CaGB) cases necessitating major hepatectomy. Methods: Between August 2015 to July 2016, seventeen patients with CaGB needing extended right hepatectomy but having insufficient FLR on CT volumetry were offered PVE. Preoperative biliary drainage (PBD) was done to decrease bilirubin to <5mg/dL. Right PVE was done by ipsilateral approach using glue and lipiodal. Volumes were reassessed after 4 weeks before considering for surgery. Results: All the 17 cases were jaundiced and therefore required PBD. 2 patients had received neo-adjuvant chemo-radiotherapy. Technical success was achieved in all and there were no procedure related complications. Mean baseline segment 2+3 volume was 16.46 ± 5.07 % which increased to 25.34 ± 7.01% post embolization. Only 2 patients could undergo curative surgery despite increase in FLR, one of whom required ALPPS procedure due to inadequate FLR on intra-operative assessment. 8 cases had tumour progression, 2 developed main portal vein thrombosis, 1 developed portal hypertension, 3 had persistent sepsis or poor performance status and 1 defaulted. There was no post operative liver failure in the operated patients. Conclusions: FLR increase after PVE doesn't translate into improved resectabilty in locally advanced but resectable CaGB cases due to further disease progression. Hence, alternative approaches should be considered in these subset of patients.

Efficacy of percutaneous transhepatic portal vein embolization using gelatin sponge particles and metal coils.

BackgroundPercutaneous transhepatic portal vein embolization (PTPE) can increase the future liver remnant (FLR) volume before extended liver resection; however, there is no current consensus regarding the best embolic material for PTPE.PurposeTo evaluate the efficacy of PTPE using gelatin sponge particles and coils.Material and MethodsThe medical records of 136 patients who underwent PTPE using gelatin sponge particles and metal coils were retrospectively reviewed. We evaluated the procedural details, liver volume on CT, and clinical status before and after PTPE.ResultsThe mean FLR volume increased significantly from 390 ± 147 cm3 to 508 ± 141 cm3 (P < 0.001). A mean of 22.1 ± 9.4 days after PTPE, the mean increase in the ratio of FLR volume to total liver volume was 9.4 ± 6.5%. Complications related to PTPE occurred in five patients, including arterial damage (n = 4) and biloma (n = 1). The white blood cell count and C-reactive protein level increased significantly and then returned to baseline within seven days. Aspartate aminotransferase and alanine aminotransferase showed no significant changes. Fever (defined by the Common Terminology Criteria for Adverse Events v4.0) was reported in 74 patients (54%), but it was generally mild (Grade 1/2; n = 72). None of the patients experienced severe complications that required cancellation of surgery.ConclusionPTPE with gelatin sponge particles and coils may impose low physical stress on patients and is a safe method of inducing a significant increase of FLR.

ALPPS as a salvage procedure after insufficient future liver remnant hypertrophy following portal vein occlusion

BackgroundA minimum future liver remnant (FLR) of 30% is required to avoid post hepatectomy liver failure (PHLF). Portal vein occlusion (PVO) is the main strategy to induce hypertrophy of the FLR, but some patients will not reach sufficient FLR hypertrophy to enable resection. Recently ALPPS has emerged as a “Salvage Procedure” for PVO failure. The aim of this study was to report the short term outcomes of ALPPS following PVO failure. MethodsA retrospective analysis of patients enrolled within the international ALPPS Registry between October 2012 and November 2015 (NCT01924741) was performed. Patients with documented PVO failure were included. The outcomes reported included feasibility, FLR growth rate and safety of ALPPS. Complications were recorded as per Clavien-Dindo classification. ResultsFrom 510 patients enrolled in the Registry there were 22 patients with previous PVO failure. Two patients were excluded due to missing data and twenty patients were analysed. All of them completed the proposed ALPPS with a medium FLR increase of 88% (23–115%) between two stages and no 90-day mortality. ConclusionIn experienced centers, ALPPS following PVO failure is feasible and safe. The FLR hypertrophy was similar to other ALPPS series. ALPPS is a potential rescue strategy after PVO failure.

Safety and efficacy of radiofrequency-assisted ALPPS (RALPPS) in patients with cirrhosis-related hepatocellular carcinoma

Background and aims: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has high morbidity and mortality. In this study, the safety and efficacy of a modification of ALPPS (radiofrequency-assisted ALPPS, RALPPS) were assessed in patients with hepatocellular carcinoma (HCC).Materials and methods: Patients who were diagnosed with HCC and were considered to have an insufficient future liver remnant (FLR) were enrolled. In stage I, a radiofrequency ablation (RFA) device was used to cauterise along the planned transection plane to form a coagulum avascular area. When the FLR reached above 40%, hepatectomy was performed in stage II along the coagulum area established previously. After two stages, operative morbidity, mortality, per cent increase in FLR, operative time and blood loss were evaluated.Results: Between July 2014 and September 2015, 10 patients with HCC (9 with hepatitis-related cirrhosis) were treated with the RALPPS procedure. The incidence of severe complications (Clavien-Dindo ≥ IIIb) was 20% (2/10). One patient died. No biliary leakage, intraperitoneal infection or post-hepatectomy liver failure (PHLF) occurred after both stages. The median FLR before stage I was 31% (364 ml). This increased to 47% (632 ml) before stage II after a median interval of 28 days. The median percentage increase in FLR was 53% (210 ml). Additionally, the median operative time during the first and second stages was 214 and 281 min, respectively. The corresponding median blood loss was 200 and 550 ml, respectively.Conclusions: RALPPS has a potential advantage in eliminating serious complications of biliary leakage and PHLF associated with classic ALPPS. On the basis of rigorous patient selection criteria, RALPPS may achieve the same effect of promoting significant growth of the FLR in patients with cirrhosis-related HCC and insufficient FLR volume, albeit at the cost of a longer interval time.

ALPPS readdresses the management of advanced liver tumors

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been developed to induce rapid liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable or marginally resectable liver tumors. In recent years, this novel strategy has aroused interests of many liver surgeons. Its indications have been broadened gradually with more and more reported cases. Modified ALPPS is also developed to reduce morbidity and mortality. The authors searched Medline and PubMed to identify related articles published in English, using terms: “ALPPS, associating liver partition and portal vein ligation for staged hepatectomy, in situ split, in situ splitting, liver partition”. The authors summarized and analysed the superiority, indications, modifications, safety, mechanisms of regeneration of ALPPS. ALPPS was more effective than traditional portal vein embolization (PVE) or portal vein ligation (PVL). ALPPS obtained 80% volume increase of future liver remnant (FLR ) within 7 days in contrast to 10%-46% within 2 to 8 weeks by PVE or PVL. ALPPS opens a chapter in the history of liver surgery and readdresses the management of advanced primary and metastatic liver tumors. The high morbidity and mortality associated with ALPPS could be decreased remarkably if we carefully select patients and carry out the operation with experienced surgeons. In addition, the safety, mechanisms and oncological outcome of ALPPS are still not clear, which need further research and randomized controlled trials.

New challenge of liver surgery: associating liver partition and portal vein ligation for staged hepatectomy

An innovative approach, named associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), has made possible a marked increase in future liver remnant (FLR) over a short period of time, and has challenged the concept of unresectability. To date, ALPPS has been employed for a variety of primary and metastatic liver tumors from many centers across the world. Many technical variations of ALPPS have been described. However, much controversy has surrounded this procedure, and many problems remain to be solved, such as the reasons for rapid hypertrophy, the technical feasibility, safety and long-term oncologic outcomes, and the result compared with the conventional two-stage hepatectomy. These aspects are needed to be evaluated further in large-scale studies. We believe that the ALPPS procedure will has much room for further development. Key words: Liver neoplasms; Associating liver partition and portal vein ligation for staged hepatectomy