Intraoperative Conversion to ALPPS in a Case of Intrahepatic Cholangiocarcinoma

Background. Surgical resection remains the best treatment option for intrahepatic cholangiocarcinoma (ICC). Two-stage liver resection combiningin situliver transection with portal vein ligation (ALPPS) has been described as a promising method to increase the resectability of liver tumors also in the case of ICC.Presentation of Case. A 46-year-old male patient presented with an ICC-typical lesion in the right liver. The indication for primary liver resection was set and planed as a right hepatectomy. In contrast to the preoperative CT-scan, the known lesion showed further progression in a macroscopically steatotic liver. Therefore, the decision was made to perform an ALPPS-procedure to avoid an insufficient future liver remnant (FLR). The patient showed an uneventful postoperative course after the first and second step of the ALPPS-procedure, with sufficient increase of the FLR. Unfortunately, already 2.5 months after resection the patient had developed new tumor lesions found by the follow-up CT-scan.Discussion. The presented case demonstrates that an intraoperative conversion to an ALPPS-procedure is safely applicable when the FLR surprisingly seems to be insufficient.Conclusion. ALPPS should also be considered a treatment option in well-selected patients with ICC. However, the experience concerning the outcome of ALPPS in case of ICC remains fairly small.

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Rescue ALPPS: Intraoperative Conversion to ALPPS during Synchronous Resection of Rectal Cancer and Liver Metastasis

Case Reports in Surgery ◽

10.1155/2014/487852 ◽

2014 ◽

Vol 2014 ◽

pp. 1-4 ◽

Cited By ~ 3

Author(s):

Terence Jackson ◽

Kelly A. Siegel ◽

Christopher T. Siegel

Keyword(s):

Liver Resection ◽

Liver Metastasis ◽

Portal Vein ◽

Future Liver Remnant ◽

Dropout Rate ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Patients At Risk ◽

Synchronous Resection ◽

Intraoperative Conversion

Future liver remnant (FLR) is the most important deciding factor in planning for liver resection. Portal vein embolization (PVE) was first introduced in the 1980s to induce liver hypertrophy, enabling removal of multiple/bilobar tumors. PVE was later combined with sequential hepatectomies with the aim of allowing the liver remnant to hypertrophy (15–20%) between procedures. However, the interval between the two procedures (3–8 weeks) put patients at risk for disease progression. With portal vein ligation alone or when combined with sequential hepatectomy, there is also a risk for inadequate liver hypertrophy because of intrahepatic portal collaterals leading to a high (19–30%) dropout rate. The ALPPS procedure (associating liver partition and portal vein ligation for staged hepatectomy) was recently developed as a feasible means to perform extensive/bilobar liver resections. It produces rapid, enormous hypertrophy of the remnant, making previously unresectable lesions resectable. Indications for ALPPS include any extensive liver resection with inadequate FLR. Here we present a novel indication for ALPPS as a rescue when inadequate FLR was faced intraoperatively, during a simultaneous resection of rectal primary and liver metastasis.

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Advances in the conventional clinical treatment for hepatoblastoma and therapeutic innovation

World Journal of Pediatric Surgery ◽

10.1136/wjps-2020-000220 ◽

2021 ◽

Vol 4 (3) ◽

pp. e000220

Author(s):

Zhixue Chen ◽

Rui Dong

Keyword(s):

Liver Transplantation ◽

Clinical Trials ◽

Portal Vein ◽

Molecular Mechanisms ◽

Liver Tumors ◽

Surgical Techniques ◽

Future Liver Remnant ◽

Portal Vein Ligation ◽

Liver Remnant ◽

New Treatments

BackgroundHepatoblastoma (HB) is a rare malignancy usually occurring in children under 3 years old. With advancements in surgical techniques and molecular biology, new treatments have been developed.Data resourcesThe recent literatures on new treatments, molecular mechanisms and clinical trials for HB were searched and reviewed.ResultsSurgical resection remains the main option for treatment of HB. Although complete resection is recommended, a resection with microscopical positive margins (R1) may have similar 5-year overall survival and 5-year event-free survival (EFS) rates after cisplatin chemotherapy and the control of metastasis, as only once described so far. Indocyanine green-guided surgery can help achieve precise resection. Additionally, associating liver partition and portal vein ligation for staged hepatectomy can rapidly increase future liver remnant volume compared with portal vein ligation or embolization. Cisplatin-containing chemotherapies slightly differ among the guidelines from the International Childhood Liver Tumors Strategy Group (SIOPEL), Children’s Oncology Group (COG) and Chinese Anti-Cancer Association Pediatric Committee (CCCG), and the 3-year EFS rate of patients in SIOPEL and CCCG studies was recently shown to be higher than that in COG studies. Liver transplantation is an option for patients with unresectable HB, and successful cases of autologous liver transplantation have been reported. In addition, effective inhibitors of important targets, such as the mTOR (mammalian target of rapamycin) inhibitor rapamycin, β-catenin inhibitor celecoxib and EpCAM (epithelial cell adhesion molecule) inhibitor catumaxomab, have been demonstrated to reduce the activity of HB cells and to control metastasis in experimental research and clinical trials.ConclusionThese advances in surgical and medical treatment provide better outcomes for children with HB, and identifying novel targets may lead to the development of future targeted therapies and immunotherapies.

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ALPPS readdresses the management of advanced liver tumors

International Surgery Journal ◽

10.18203/2349-2902.isj20170842 ◽

2017 ◽

Vol 4 (3) ◽

pp. 846 ◽

Cited By ~ 1

Author(s):

Fa-guang Huang ◽

Jiang-Hua Xiao ◽

Jun Kong ◽

Jian Ping Gong

Keyword(s):

Portal Vein ◽

Liver Tumors ◽

Future Liver Remnant ◽

Oncological Outcome ◽

Morbidity And Mortality ◽

High Morbidity ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Staged Hepatectomy

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.

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In situliver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection

British Journal of Surgery ◽

10.1002/bjs.8955 ◽

2012 ◽

Vol 100 (3) ◽

pp. 388-394 ◽

Cited By ~ 111

Author(s):

W. T. Knoefel ◽

I. Gabor ◽

A. Rehders ◽

A. Alexander ◽

M. Krausch ◽

...

Keyword(s):

Liver Resection ◽

Portal Vein ◽

Rapid Growth ◽

Future Liver Remnant ◽

Portal Vein Ligation ◽

Two Stage ◽

Liver Remnant ◽

The Future

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Percutaneous Radio-frequency Assisted Liver Partition with Portal vein embolization in Staged liver resection (PRALPPS) in patients with perihilar and intrahepatic cholangiocarcinoma: evaluation of short-term results

Grekov s Bulletin of Surgery ◽

10.24884/0042-4625-2019-178-2-22-27 ◽

2019 ◽

Vol 178 (2) ◽

pp. 22-27

Author(s):

O. V. Melekhina ◽

M. G. Efanov ◽

R. B. Alikhanov ◽

V. V. Tsvirkun ◽

Yu. V. Kulezneva ◽

...

Keyword(s):

Growth Rate ◽

Liver Resection ◽

Intrahepatic Cholangiocarcinoma ◽

Future Liver Remnant ◽

Safe Procedure ◽

Short Term ◽

Liver Remnant ◽

Major Morbidity ◽

Kinetic Growth ◽

Stage 1

Objective. To estimate the short-term results of modified variant of ALPPS (PRALPPS) in patients with perihilar and intrahepatic cholangiocarcinoma.Material and methods. Procedure was indicated for future liver remnant <40%.Results. PRALPPS was applied in 13 patients and completed in 10 patients. Degree of hypertrophy and kinetic growth rate were 48 and 4.3%/day respectively. Major morbidity (>II) after the stage 1 and 2 was presented in 3 (only IIIa) and 7 patients, respectively.Conclusion. PRALPPS may be considered as an effective and safe procedure in patients with perihilar and intrahepatic cholangiocarcinoma.

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Portal vein embolization with n-butyl-cyanoacrylate before hepatectomy: a single-center retrospective analysis of 46 consecutive patients

Acta Radiologica ◽

10.1177/0284185120953802 ◽

2020 ◽

pp. 028418512095380

Author(s):

Marijela Moreno Berggren ◽

Bengt Isaksson ◽

Rickard Nyman ◽

Charlotte Ebeling Barbier

Keyword(s):

Liver Resection ◽

Portal Vein ◽

Local Anesthesia ◽

Portal Vein Embolization ◽

Liver Tumors ◽

Future Liver Remnant ◽

Liver Remnant ◽

Total Liver Volume ◽

Computed Tomography Images ◽

The Future

Background Preoperative portal vein embolization (PVE) is performed to induce hypertrophy of the future liver remnant enabling major liver resection in patients with various types of liver tumors. Purpose To evaluate safety and effectiveness of PVE with n-butyl-cyanoacrylate (NBCA). Material and Methods All consecutive patients referred to our hospital for PVE between July 2006 and July 2017 were retrospectively reviewed. Volumetry was performed on computed tomography images before and after PVE, segmenting the total liver volume and the future liver remnant (FLR), i.e. liver segments I–III. Results PVE was performed in 46 patients (18 women, 28 men; mean age = 61 years) using local anesthesia. The ipsilateral technique was used in 45 patients. Adverse events were rare. The mean FLR volume increase was 56%, the degree of hypertrophy was 9.7%, and the kinetic growth rate was 2.1%/week. The median ± SD period between PVE and liver surgery was 7 ± 3 weeks. Forty-two patients (91%) had surgery; liver resection was performed in 37 (80%) patients. Three patients (7%) developed transient liver failure after surgery. There was no 90-day post-PVE or postoperative mortality. Conclusion PVE using NBCA through the ipsilateral approach in local anesthesia is safe and effective in inducing hypertrophy of the future liver remnant enabling surgery, and thereby increasing survival in patients with liver tumors.

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Future Liver remnant: A challenge in liver resection surgery

Journal of Society of Surgeons of Nepal ◽

10.3126/jssn.v18i3.15309 ◽

2016 ◽

Vol 18 (3) ◽

pp. 47

Author(s):

S Regmee ◽

TY Tamang ◽

DK Maharjan ◽

SK Shrestha ◽

PB Thapa

Keyword(s):

Liver Resection ◽

Liver Volume ◽

Future Liver Remnant ◽

College Teaching ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Medical College ◽

First Case ◽

Transplant Center ◽

And Function

Introduction and Objective: The frontiers of liver resection are expanding. Future Liver Remnant; its volume, function and complication have a predictive value in post resection outcome including post resection liver failure. This study is directed to discuss the issues related to future liver remnant.Objective: To discuss issues related to Future Liver Remnant in patients planned for major liver resectionMaterials and Methods: Data of patients admitted for liver resection at Kathmandu Medical College Teaching Hospital, Surgical Unit III with varied diagnosis, were collected prospectively over a period of 1 year. In our non transplant center, Future Liver Remnant was managed with varying methods. Of the 12 liver resections, 3 prototype cases with different FLR issues are discussed in this study.Results: The first case had issue related to the volume of the liver remnant for which she underwent a portal vein ligation followed by resection (after adequate volume increase) in the second surgery. The second case was a Hepatocellular Carcinoma with CTP 8 cirrhosis. Despite adequate liver volume, decision for liver resection was delayed due to possible postoperative decompensation. The third patient was a Hilar cholangiocarcinoma with obstructive jaundice. Biliary decompression (PTBD) was performed. However, inadequate fall in bilirubin caused dilemma for liver resection. Despite the dilemma, all 3 cases underwent liver resection with no postoperative liver failure.Conclusion: Issues related to the volume and function of future liver remnant in patient undergoing liver resection should be adequately addressed by various pre operative, intra operative, and post operative measures.

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