Two-stage Hepatectomy In Patients Research Articles

Tumor Progression Molecular Pathways after ALPPS and Conventional Two-stage Hepatectomy in Patients with Colorectal Liver Metastases

Tumor Progression Molecular Pathways after ALPPS and Conventional Two-stage Hepatectomy in Patients with Colorectal Liver Metastases

ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases

ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases

Response To “ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases”

Response To “ALPPS Versus Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastases”

ALPPS improves resectability compared to conventional two-stage hepatectomy in patients with advanced colorectal liver metastasis

The aim was to evaluate ALPPS could increase resection rates (RRs) compared with two stage hepatectomy (TSH) in a randomized controlled trial (RCT). Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails. A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of < 30%. Primary outcome, resection rates (RRs) were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality and 90-day mortality measured from the final intervention. Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% (C.I. 84-100%)(44/48) in the ALPPS arm compared to 57% (43-72%)(28/49) in the TSH arm (rate ratio 8.25 [95% CI 2.6-26.6]; P< 0.0001). No differences in complications (Clavien-Dindo ≥3a) (43% (19/44) vs. 43% (12/28) (1.01 [95% CI 0.4-2.6]; P=0.99), 90-day mortality (8.3% (4/48) vs. 6.1% (3/49) (1.39 [95% CI 0.3-6.6]; P=0.68) or R0 RRs (77% (34/44) vs. 57% (16/28) (2.55 [95% CI 0.9-7.1]; P=0.11)) were observed. Of the patients in the TSH arm that failed to reach a sFLR of 30%, 12 were successfully treated with ALPPS. ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications and short-term mortality.

Letter to the Editor Regarding “ALPPS Improves Resectability Compared with Conventional Two-Stage Hepatectomy in Patients with Advanced Colorectal Liver Metastasis”

Letter to the Editor Regarding “ALPPS Improves Resectability Compared with Conventional Two-Stage Hepatectomy in Patients with Advanced Colorectal Liver Metastasis”

ALPPS Improves Resectability Compared With Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastasis: Results From a Scandinavian Multicenter Randomized Controlled Trial (LIGRO Trial).

Objective:The aim of the study was to evaluate if associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) could increase resection rates (RRs) compared with two-stage hepatectomy (TSH) in a randomized controlled trial (RCT).Background:Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails due to insufficient liver growth or tumor progression.Methods:A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of less than 30%. Primary outcome—RRs were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality, and 90-day mortality measured from the final intervention.Results:Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% [95% confidence interval (CI) 84%–100%] (44/48) in the ALPPS arm compared with 57% (95% CI 43%–72%) (28/49) in the TSH arm [rate ratio 8.25 (95% CI 2.6–26.6); P < 0.0001]. No differences in complications (Clavien–Dindo ≥3a) [43% (19/44) vs 43% (12/28)] [1.01 (95% CI 0.4–2.6); P = 0.99], 90-day mortality [8.3% (4/48) vs 6.1% (3/49)] [1.39 [95% CI 0.3–6.6]; P = 0.68] or R0 RRs [77% (34/44) vs 57% (16/28)] [2.55 [95% CI 0.9–7.1]; P = 0.11)] were observed. Of the patients in the TSH arm that failed to reach an sFLR of 30%, 12 were successfully treated with ALPPS.Conclusion:ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications, and short-term mortality.

Two-stage hepatectomy for multiple giant alveolar echinococcosis.

Alveolar echinococcosis is a chronically progressive and potentially fatal disease. Patients with multiple giant alveolar echinococcosis have a poor prognosis when radical resection cannot be achieved, but curative resection can be limited by low future remnant liver volumes. In these cases, 2-stage liver resection may be a better choice: after a first-stage hepatectomy with partial resection, liver regeneration is allowed in the residual liver before proceeding to the second-stage hepatectomy. In this study, we therefore retrospectively reviewed and evaluated the safety and feasibility of two-stage hepatectomy in patients with multiple giant alveolar echinococcosis.We reviewed the data for all patients who underwent 2-stage hepatectomy for multiple giant alveolar echinococcosis between August 2013 and December 2015 at either the West China Hospital of Sichuan University or the Hospital of Ganzi Tibetan Autonomous Prefecture.We identified 7 patients in whom 2-stage hepatectomy was completed. During the first-stage hepatectomy, 4 patients underwent right-sided hepatectomy and the other 3 underwent left-sided hepatectomy. The second-stage hepatectomies were successfully performed 3 months after the first-stage procedures. All patients had follow-up durations of >1 year; there were no cases of operation-related mortality, and no patients experienced disease recurrence.Two-stage hepatectomy is safe and feasible for patients with multiple giant alveolar echinococcosis.

Abdominal cross-sectional imaging of the associating liver partition and portal vein ligation for staged hepatectomy procedure

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a recently introduced technique aimed to perform two-stage hepatectomy in patients with a variety of primary or secondary neoplastic lesions. ALPSS is based on a preliminary liver resection associated with ligation of the portal branch directed to the diseased hemiliver (DH), followed by hepatectomy after an interval of time in which the future liver remnant (FLR) hypertrophied adequately (partly because of preserved arterialization of the DH). Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) play a pivotal role in patients’ selection and FLR assessment before and after the procedure, as well as in monitoring early and late complications, as we aim to review in this paper. Moreover, we illustrate main abdominal MDCT and MRI findings related to ALPPS.

Efficacy and Safety of Portal Vein Embolization for Two-Stage Hepatectomy in Patients with Colorectal Liver Metastasis

PurposeTo examine the efficacy and safety of portal vein embolization (PVE) when used during two-stage hepatectomy for bilobar colorectal liver metastases (CLM). Materials and MethodsPVE was performed as an adjunct to two-stage hepatectomy in 56 patients with CLM. Absolute future liver remnant (FLR) volumes, standardized FLR ratios, degree of hypertrophy (DH), and complications were analyzed. Segment II and III volumes and DH were also measured separately. All volumetric measurements were compared with a cohort of 96 patients (n = 37 right portal vein embolization [RPVE], n = 59 right portal vein embolization extended to segment IV portal veins [RPVE+4]) in whom PVE was performed before single-stage hepatectomy. ResultsFor patients who completed RPVE during two-stage hepatectomy (n = 17 of 17), mean absolute FLR volume increased from 272.1 cm3 to 427.0 cm3 (P < .0001), mean standardized FLR ratio increased from 0.17 to 0.26 (P < .0001), and mean DH was 0.094. For patients who completed RPVE+4 during two-stage hepatectomy (n = 38 of 39), mean FLR volume increased from 288.7 cm3 to 424.8 cm3 (P < .0001), mean standardized FLR increased from 0.18 to 0.26 (P < .0001), and mean DH was 0.083. DH of the FLR was not significantly different between two-stage hepatectomy and single-stage hepatectomy. Complications after PVE occurred in five (8.9%) patients undergoing two-stage hepatectomy. ConclusionsPVE effectively and safely induced a significant DH in the FLR during two-stage hepatectomy in patients with CLM.

2:42 PM Abstract No. 205 - Portal vein embolization for two-stage hepatectomy in patients with colorectal liver metastasis: safety, efficacy, and value of including segment 4

Purpose To examine the efficacy and safety of portal vein embolization (PVE) on future liver remnant (FLR) hypertrophy when used between the first and second stage of two-stage hepatectomy (TSH) in patients with colorectal liver metastases (CLM). Secondary purpose was to evaluate the effect of extending right portal vein embolization (RPVE) to segment 4 (RPVE + 4) on hypertrophy of segments 2 + 3 (S2 + 3). Materials and Methods IRB-approved retrospective cohort study performed from May 1998 to January 2011. Fifty-one patients with CLM underwent PVE as an adjunct to TSH; RPVE was performed in 16 and RPVE + 4 was performed in 35. Absolute FLR volumes, standardized future liver remnant (sFLR) ratios, degree of hypertrophy (DH), and complications were recorded and analyzed with t-tests. To assess the value of extending RPVE to segment 4 in the setting of TSH, absolute volumes and DH were measured for S2 + 3 for all 51 TSH patients. All volumetric measurements were compared to a control cohort composed of 96 patients (n = 37 RPVE, n = 59 RPVE + 4) in whom PVE was performed as an adjunct to single stage hepatectomy (SSH) during the same time period. Results For patients who completed RPVE as an adjunct to TSH (n = 16/16), absolute FLR volume increased from 268.3 mL to 427.3 mL (p Conclusion PVE is an effective and safe technique to induce a significant DH in the FLR prior to definitive stage 2 hepatectomy. Unlike SSH, extending RPVE to RPVE + 4 for TSH does not appear to induce a significant hypertrophy of S2 + 3 volumes.

A comparative study of patients with and without associated digestive surgery in a two-stage hepatectomy setting

The purpose of this study was to compare the feasibility and outcomes of two-stage hepatectomy in patients with or without accompanying digestive surgery. We analyzed prospectively data from 56 patients with colorectal liver metastases undergoing two-stage hepatectomy between 1995 and 2009. Patients undergoing associated digestive resection (group I, n = 32) were compared with patients without associated digestive surgery (group II, n = 17). The feasibility rate was 87.5% (49 patients). Neither the type and extent of hepatectomy nor the type of chemotherapy administered differed between the two groups. The median interval between hepatectomies was 1.79 and 2.07 months for groups I and II, respectively (not significant). One patient (group I) died of liver failure after the second hepatectomy. Postoperative morbidity rates were comparable: 37.5% (group I) vs. 35.5% (group II) after the first hepatectomy and 46.9% (group I) vs. 52.9% (group II) after the second hepatectomy. The median hospital stay after the first hepatectomy was longer in group I (13.5 days) than in group II (10 days) (P < 0.01). Median follow-up was 54 months. The median overall survival (OS) was 45.8 months, and 3- and 5-year OS were 58 and 31%, respectively. Median OS was longer for group II (58 months) than for group I (34 months) (P = 0.048). Digestive tract resection associated with two-stage hepatectomy does not increase postoperative mortality or morbidity nor does it lead to delay in chemotherapy or a reduction in cycles administered. The need for digestive tract surgery should not affect the surgical management of two-stage hepatectomy patients.

Combined first-stage hepatectomy and colorectal resection in a two-stage hepatectomy strategy for bilobar synchronous liver metastases

This study assessed the feasibility and outcomes of combined colorectal and hepatic resection as the first step of two-stage hepatectomy in patients with bilobar synchronous colorectal liver metastases. All patients with bilobar synchronous colorectal liver metastases who were considered for two-stage hepatectomy, combining resection of the primary tumour with the first stage of hepatectomy, between 2000 and 2008 were selected from a prospectively collected database at two institutions. Data were analysed retrospectively on an intention-to-treat basis. Thirty-three patients were studied. Twenty patients received neoadjuvant chemotherapy. Combined colorectal resection and clearance of left-sided liver metastases was the first-stage procedure in all but one patient, in whom right clearance was performed. In 17 patients right portal vein ligation was undertaken at the same time. No patient died. Two patients had anastomotic leakage. Interval chemotherapy was given to 25 patients, five of whom also had percutaneous portal vein embolization. Twenty-five patients had the second-stage hepatectomy, but not eight patients with disease progression. There was one postoperative death after the second stage, and eight patients experienced morbidity. Median follow-up from the first stage was 28.7 months. Overall and disease-free survival rates for patients who completed the procedure were 80 and 44 per cent respectively at 3 years, and 48 and 22 per cent at 5 years. In patients with bilobar synchronous colorectal liver metastases who are candidates for two-stage hepatectomy, combined resection of the primary tumour and first-stage hepatectomy reduces the number of procedures, optimizes chemotherapy administration and may improve outcome.