Accepted Manuscript The ALPPS Approach Using Only Segments I and IV as Future Liver Remnant Martin de Santibañes , MD Fernando A. Alvarez , MD Fanny Rodriguez Santos , MD Victoria Ardiles , MD Eduardo de Santibañes , MD, PhD, FACS PII:
S1072-7515(14)00398-6
DOI:
10.1016/j.jamcollsurg.2014.01.070
Reference:
ACS 7397
To appear in:
Journal of the American College of Surgeons
Received Date: 12 November 2013 Revised Date:
29 January 2014
Accepted Date: 29 January 2014
Please cite this article as: de Santibañes M, Alvarez FA, Santos FR, Ardiles V, de Santibañes E, The ALPPS Approach Using Only Segments I and IV as Future Liver Remnant, Journal of the American College of Surgeons (2014), doi: 10.1016/j.jamcollsurg.2014.01.070. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT The ALPPS Approach Using Only Segments I and IV as Future Liver Remnant
Victoria Ardiles, MD, Eduardo de Santibañes, MD, PhD, FACS
RI PT
Martin de Santibañes, MD, Fernando A. Alvarez, MD, Fanny Rodriguez Santos, MD,
SC
Hepato-pancreato-biliary and Liver Transplant Sections, General Surgery Service. Hospital
M AN U
Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH. Buenos Aires, Argentina
Correspondence address:
TE D
Martin de Santibañes, MD Peron 4190. CP 1181 CABA- Argentina
EP
e-mail: [email protected]
AC C
TEL: +5411 4959 0200
FAX: Fax: +54-11 4981 4041
Disclosure Information: Nothing to disclose.
Short Title: ALPPS to Prevent Posthepatectomy Liver Failure
ACCEPTED MANUSCRIPT Liver resection, with or without chemotherapy, remains the only treatment with the potential 1, 2, 3
of curing malignant liver tumours
. Frequently, major liver resections are mandatory to
achieve tumor-free surgical margins 4. One of the most severe complications associated with extended resections is posthepatectomy liver failure (PHLF). The best candidates for liver
RI PT
resection with curative intention are those who have enough parenchymal reserve, which should be at least 20% of the total liver volume in the case of a healthy future liver remnant (FLR) 5, 6, and between 30-40% in patients with chemotherapy related liver injury, fibrosis 7, 8
. Portal vein occlusion has become the gold standard strategy to regenerate
SC
orsteatosis
the FLR with a low morbidity, allowing up to 20–35% hypertrophy in 45 days 9,
10, 11
.
M AN U
However, up to 40% of patients treated with this approach are finally not candidates for resection, either because of tumor progression during the interval period or insufficient FLR hypertrophy12. Recently, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been introduced as a strategy for preventing PHLF by inducing a
TE D
rapid (one week) and large FLR volume increase (21-200%) 13,
14, 15
. Briefly, during the first
surgical stage, the complete removal of any tumor in the FLR must be completed whenever bilateral disease is present. Then the liver parenchyma is transected and portal vein ligation of
EP
the tumor-bearing side is applied. The second stage is performed when a sufficient
AC C
hypertrophy of the FLR is demonstrated, usually as a right hepatectomy or trisectionectomy, leaving the left lateral segments of the liver (segments II and III) as part of the FLR. Here we describe a new surgical strategy using the principles of the ALLPS technique, preserving only segments I and IV as the FLR.
SURGICAL TECHNIQUE The basic principle of the ALPPS approach is to prevent PHLF by a rapid and effective hypertrophy of the FLR. The indications for this innovative surgical strategy includes patients
ACCEPTED MANUSCRIPT with marginally resectable or primarily non-resectable locally advanced liver tumors of any origin with an insufficient FLR either in volume or quality16. With regards to the present surgical variation of the ALPPS approach, it is indicated in patients with bilateral disease and a high tumor load in the left lateral segment, precluding its use as a part of the FLR (Fig. 1).
RI PT
Preoperative volumetric analysis of the predicted FLR with multidetector computed tomography (MDCT) or magnetic resonance (MR) is a crucial element of surgical planning
SC
(Fig. 2).
Stage 1
M AN U
The procedure begins with a bilateral subcostal incision with midline extension. The entire abdominal cavity is explored to rule out intra or extrahepatic disease that might preclude resectability. Intraoperative doppler ultrasound (IOUS) of the liver allows a correct evaluation of the vasculo-biliary anatomy and its relationship with tumor lesions, monitoring
TE D
the level of resection, the potential for resectability and the detection of new lesions. Once resectability is confirmed, the left liver is mobilized by taking down the falciform, the left triangular and the coronary ligaments. The next step is to mobilize the right lobe -including
EP
the right coronary and triangular ligaments- then isolate and divide all accessory hepatic veins localized in the right and anterior aspect of the inferior vena cava. The right hepatic
AC C
vein is dissected and encircled. Cholecystectomy is performed and the cystic duct is marked for further transcystic manipulation. Subsequently, the attention is directed towards the hepatoduodenal ligament, where a complete lymphadenectomy is carried out. This surgical maneuver has an oncological purpose and is also helpful for the identification of anatomical variations (Fig. 3). The hepatic pedicle is encircled for the eventual need of a Pringle maneuver during liver partition. Then, an aggressive clean-up of the hepatic lesions in the
ACCEPTED MANUSCRIPT FLR (segments IV and I) is carried out, putting emphasis on not compromising the inflow or outflow of these segments (Fig. 4). Before starting the parenchymal transection, the vascular inflow and outflow of segments I and IV (that will represent the FLR) should be assessed with IOUS after clamping the right
RI PT
portal vein (RPV). Once a proper vascularization is certified, the RPV is sectioned (Fig. 5) and liver partition is carried out through the Cantlie’s line. Cavitron ultrasonic surgical aspirator in combination with the harmonic scalpel and cautery is used for parenchymal
SC
partition. The anterior and posterior right hepatic pedicle branches are isolated and encircled with silks or vessel loops for a better identification during the second stage (Fig. 6). During
M AN U
this step, it is important to prevent right hepatic artery injuries because it is the only vascular inflow of this hemi-liver. Careful control of the haemostasis is performed with Argon been, sutures and haemostatic agents.
Once it is certified that the ALPPS is technically feasible, the resection of the left lateral
TE D
segment due to high tumor load can be carried out (Fig. 7). The parenchymal transection line is marked 1 cm to the left of the falciform ligament in order to preserve segment IV vascular and biliary pedicles. The left lateral segment pedicle is dissected and ligated inside the
EP
umbilical plate. The ligament of Arantius is subsequently divided, and the confluence of the
AC C
middle and left hepatic veins isolated. Finally, the left hepatic vein is sutured isolating the left lateral segment from segment IV. At this point an IOUS is performed in order to ensure adequate inflow and outflow of the FLR. In order to detect biliary fistulas, a transcystic hydraulic test and cholangiography are routinely performed. To simplify the second stage, a plastic sheath is placed between the cut surfaces. Two drains are situated in the transection line and the right sub-phrenic space.
ACCEPTED MANUSCRIPT Stage 2 During postoperative day 6, a volumetric MDCT or MR of the FLR (segments IV and I) is performed in order to confirm liver hypertrophy and a tumor-free FLR. If the patient is in good condition and volumetric analyses showed a sufficient FLR hypertrophy, the
RI PT
completion surgery is scheduled for the following day.
The previous incision is used to enter the abdominal cavity. After releasing lax adhesions, the plastic sheath is removed and sent for microbiological analyses. An IOUS is performed in the
SC
FLR to certify a patent hepatic artery and portal vein. The anterior and posterior right pedicles that were encircled during stage 1 are recognized and ligated. The right hepatic vein
M AN U
is divided and sutured in a running fashion and the right hepatectomy is completed (Fig. 8). At the end of the procedure, a hydraulic test and cholangiography whenever possible is recommended to certify the absence of bile leaks.
TE D
DISCUSSION
Major liver resections continue to be associated with substantial morbidity and mortality particularly related with PHLF. Portal vein occlusion remains the gold standard technique to
EP
guarantee a sufficient FLR. However, patients with diabetes or severe sinusoidal injury (common situation in this population of patients) can be associated with impaired initial
AC C
growth of the FLR 17. Up to 40% of patients are not candidates for surgical resection, either because of tumor progression or insufficient FLR hypertrophy. Embolization of segment IV portal branches carries a considerable risk of accidental thrombosis or injury of the left portal vein, which vascularizes the FLR 18. The ALLPS approach has emerged as a new surgical strategy to increase resectability in patients with locally advanced oncological disease by a rapid FLR hypertrophy. Schnitzbauer et al13 described the initial multicentric German experience with the ALPPS technique in 25 patients with primary or metastatic liver tumors,
ACCEPTED MANUSCRIPT using the left lateral segments as part of the FLR. However, only patients with a tumor-free left lateral segment were included in the study. In our experience we have included patients with multiple bilobar disease, to whom we performed the resection (clean-up) of those lesions in the left lateral segment or the right posterior segments (VI and VII) as part of the
RI PT
FLR16.
Recently Gauzolino et al.19 presented different technical variations of the ALPPS approach, including the “left ALPPS”, the “right ALPPS” and the so-called “rescue ALPPS” in patients
SC
with failed PVE. However, there are no reports regarding the complete resection of segments II and III as an extreme clean-up of the FLR when performing a right hepatectomy during
M AN U
ALPPS. In this situation, only segments I and IV comprise the FLR. In the present manuscript we highlighted the technical aspects that we believe are important to safely perform this original variation of the ALPPS approach. Regarding the particular technical aspect of using a plastic sheath to minimize adhesions, the main disadvantage is that the
TE D
patient might still require a reoperation to remove this foreign body if the second stage cannot be performed. With this in mind, other authors have reported the use of absorbable material with favourable results20. To date we have treated 29 patients with the ALPPS approach, and
EP
in two cases we used the technique described in the present manuscript. Both patients suffered from colorectal liver metastases and were males of 69 and 77 years-old respectively.
AC C
During the postoperative period, both experienced a mild elevation of the bilirubin levels that recovered before 72 hs after the second stage. None of the patients suffered PHLF but one of them developed pleural effusion, acute renal insufficiency and inguinal hematoma due to a dialysis catheter that prolonged the hospital stay. Both patients were discharged fully recovered at 15 and 43 days after the first stage procedure. At follow-up, one patient is disease-free seven months after surgery and the other patient died from brain metastases five months after the procedure.
ACCEPTED MANUSCRIPT Given the fact that the ALPPS approach is a very complex and challenging two-stage procedure, it must be taken into account that it should be undertaken only by hepatobiliary specialists at high-volume centers.
RI PT
REFERENCES
1. Kavolius J, Fong Y, Blumgart LH. Surgical resection of metastatic liver tumors. Surg. Oncol. Clin.
SC
North Am. 1996;5:337.
2. Adam R, Laurent A, Azoulay D, et al. Two- stage hepatectomy: A planned strategy to treat
M AN U
irresectable liver tumors. Ann Surg. 2000;232:777–85.
3. D’Angelica M, Brennan MF, Fortner JG, et al. Ninety-six five-year survivors after liver resection for metastatic colorectal cancer. J. Am. Coll. Surg. 1997;185:554.
4. Liu H, Zhu S. Present status and future perspectives of preoperative portal vein embolization. Am J Surg. 2009;197:686–690.
TE D
5. Charnsangavej C, Clary B, Fong Y, et al. Selection of patients for resection of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol. 2006;13(10):1261-8. 6. Chun YS, Vauthey JN. Extending the frontiers of resectability in advanced colorectal cancer. Eur J
EP
Surg Oncol. 2007;33(2):52-8.
AC C
7. Nordlinger B, Van Cutsem E, Gruenberger T, et al. Combination of surgery and chemotherapy and the role of targeted agents in the treatment of patients with colorectal liver metastases: recommendations from an expert panel. Ann Oncol. 2009;20(6):985-92. 8. Wolf PS, Park JO, Bao F, et al. Preoperative chemotherapy and the risk of hepatotoxicity and morbidity after liver resection for metastatic colorectal cancer: a single institution experience. J Am Coll Surg. 2013;216(1):41-9. 9. Kishi Y, Abdalla EK, Chun YS, et al. Three Hundred and One Consecutive Extended Right Hepatectomies: Evaluation of Outcome Based on Systematic Liver Volumetry. Ann Surg. 2009;250 (4):540-548.
ACCEPTED MANUSCRIPT 10. Abulkhir A, Limongelli P, Healey AJ et al. Preoperative portal vein embolization for major liver resection: a meta-analysis. Ann Surg. 2008;247:49–57. 11. Hemming AW, Reed AI, Howard RJ et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg. 2003;237:686–691.
RI PT
12. Mueller L, Hillert C, Möller L, et al. Major hepatectomy for colorectal metastases: is preoperative portal occlusion an oncolog- ical risk factor? Ann Surg Oncol. 2008;15(7):1908–17.
13. Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portal vein ligation combined with in situ
resec- tion in small-for-size settings. Ann Surg. 2012;255:405–14.
SC
splitting induces rapid left lateral liver lobe hypertrophy enabling two-staged extended right hepatic
M AN U
14. de Santibañes E, Clavien PA. Playing Play-Doh to prevent post- operative liver failure: the “ALPPS” approach. Ann Surg. 2012;255(3):415–7.
15. Donati M, Stavrou GA, Basile F, et al. Combination of in situ split and portal ligation: lights and shadows of a new surgical procedure. Ann Surg. 2012;256(3):e11–2. author reply e16–9. 16. Alvarez FA, Ardiles V, Sanchez Claria R, et al. Associating Liver Partition and Portal Vein
TE D
Ligation for Staged Hepatectomy (ALPPS): Tips and Tricks. J Gastrointest Surg. 2013 Apr;17(4):814-21.
17. Shindoh J, Truty MJ, Aloia TA, et al. Kinetic growth rate after portal vein embolization predicts
EP
posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant. J Am Coll Surg. 2013 Feb;216(2):201-9.
AC C
18. Loos M, Friess H. Is there new hope for patients with marginally resectable liver malignancies. World J Gastrointest Surg. 2012 Jul 27;4(7):163-5. 19. Gauzolino R, Castagnet M, Blanleuil ML, Richer JP. The ALPPS technique for bilateral colorectal metastases: three "variations on a theme". Updates Surg. 2013;65(2):141-8. 20. Schnitzbauer AA, Lang SA. ALPPS: Response to letter to the editor. Ann Surg. 2012;256(3):e167.
ACCEPTED MANUSCRIPT FIGURE LEGENDS
Figure 1: Surgical exploration demonstrating a liver with an extensive tumor load. Metastatic lesions are presents in all segments of the liver. Segment IV clean-up is planned in order to become part of
RI PT
the future liver remnant (dotted lines). (Drawing by coauthor Fanny Rodriguez Santos.) Figure 2: A. Preoperative liver volumetric MR in a 77-year-old patient with multiple bilateral colorectal liver metastases who received 6 cycles of chemotherapy. B. The estimated future liver remnant volume (FLR) including segments I and IV was 305 ml. The FLR represented only 20% of
SC
the total liver volume.
Figure 3: Portal pedicle lymphadenectomy during the first stage of ALPPS. A black silk is around the
M AN U
portal triad. The left portal vein is encircled with a blue vessel loop, the right hepatic artery with a red vessel loop and the left hepatic artery with a white vessel loop. Bile duct is pointed with an asterisk and the cystic duct with a black arrow.
Figure 4: Atypical resections (clean-up) of metastatic lesions in segments IVa and IVb.
TE D
Figure 5: The right portal vein is divided between clamps and sutured in a running fashion. Figure 6: Liver partition at the level of the Cantlie’s line using the hanging maneuver. The right hepatic vein (white arrowhead) as well as the anterior and posterior right hepatic pedicles are
EP
encircled with light blue ties.
Figure 7: Left lateral resection due to extensive metastatic compromise. (Drawing by coauthor Fanny
AC C
Rodriguez Santos.)
Figure 8: Intraoperative photo during the second stage of ALPPS. A 152% hypertrophy was demonstrated on preoperative volumetric analysis and observed intraoperatively. The hypertrophied liver remnant (771 ml) is seen after the resection of the disease hemi-liver.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1072-7515(14)00398-6
DOI:
10.1016/j.jamcollsurg.2014.01.070
Reference:
ACS 7397
To appear in:
Journal of the American College of Surgeons
Received Date: 12 November 2013 Revised Date:
29 January 2014
Accepted Date: 29 January 2014
Please cite this article as: de Santibañes M, Alvarez FA, Santos FR, Ardiles V, de Santibañes E, The ALPPS Approach Using Only Segments I and IV as Future Liver Remnant, Journal of the American College of Surgeons (2014), doi: 10.1016/j.jamcollsurg.2014.01.070. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT The ALPPS Approach Using Only Segments I and IV as Future Liver Remnant
Victoria Ardiles, MD, Eduardo de Santibañes, MD, PhD, FACS
RI PT
Martin de Santibañes, MD, Fernando A. Alvarez, MD, Fanny Rodriguez Santos, MD,
SC
Hepato-pancreato-biliary and Liver Transplant Sections, General Surgery Service. Hospital
M AN U
Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH. Buenos Aires, Argentina
Correspondence address:
TE D
Martin de Santibañes, MD Peron 4190. CP 1181 CABA- Argentina
EP
e-mail: [email protected]
AC C
TEL: +5411 4959 0200
FAX: Fax: +54-11 4981 4041
Disclosure Information: Nothing to disclose.
Short Title: ALPPS to Prevent Posthepatectomy Liver Failure
ACCEPTED MANUSCRIPT Liver resection, with or without chemotherapy, remains the only treatment with the potential 1, 2, 3
of curing malignant liver tumours
. Frequently, major liver resections are mandatory to
achieve tumor-free surgical margins 4. One of the most severe complications associated with extended resections is posthepatectomy liver failure (PHLF). The best candidates for liver
RI PT
resection with curative intention are those who have enough parenchymal reserve, which should be at least 20% of the total liver volume in the case of a healthy future liver remnant (FLR) 5, 6, and between 30-40% in patients with chemotherapy related liver injury, fibrosis 7, 8
. Portal vein occlusion has become the gold standard strategy to regenerate
SC
orsteatosis
the FLR with a low morbidity, allowing up to 20–35% hypertrophy in 45 days 9,
10, 11
.
M AN U
However, up to 40% of patients treated with this approach are finally not candidates for resection, either because of tumor progression during the interval period or insufficient FLR hypertrophy12. Recently, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been introduced as a strategy for preventing PHLF by inducing a
TE D
rapid (one week) and large FLR volume increase (21-200%) 13,
14, 15
. Briefly, during the first
surgical stage, the complete removal of any tumor in the FLR must be completed whenever bilateral disease is present. Then the liver parenchyma is transected and portal vein ligation of
EP
the tumor-bearing side is applied. The second stage is performed when a sufficient
AC C
hypertrophy of the FLR is demonstrated, usually as a right hepatectomy or trisectionectomy, leaving the left lateral segments of the liver (segments II and III) as part of the FLR. Here we describe a new surgical strategy using the principles of the ALLPS technique, preserving only segments I and IV as the FLR.
SURGICAL TECHNIQUE The basic principle of the ALPPS approach is to prevent PHLF by a rapid and effective hypertrophy of the FLR. The indications for this innovative surgical strategy includes patients
ACCEPTED MANUSCRIPT with marginally resectable or primarily non-resectable locally advanced liver tumors of any origin with an insufficient FLR either in volume or quality16. With regards to the present surgical variation of the ALPPS approach, it is indicated in patients with bilateral disease and a high tumor load in the left lateral segment, precluding its use as a part of the FLR (Fig. 1).
RI PT
Preoperative volumetric analysis of the predicted FLR with multidetector computed tomography (MDCT) or magnetic resonance (MR) is a crucial element of surgical planning
SC
(Fig. 2).
Stage 1
M AN U
The procedure begins with a bilateral subcostal incision with midline extension. The entire abdominal cavity is explored to rule out intra or extrahepatic disease that might preclude resectability. Intraoperative doppler ultrasound (IOUS) of the liver allows a correct evaluation of the vasculo-biliary anatomy and its relationship with tumor lesions, monitoring
TE D
the level of resection, the potential for resectability and the detection of new lesions. Once resectability is confirmed, the left liver is mobilized by taking down the falciform, the left triangular and the coronary ligaments. The next step is to mobilize the right lobe -including
EP
the right coronary and triangular ligaments- then isolate and divide all accessory hepatic veins localized in the right and anterior aspect of the inferior vena cava. The right hepatic
AC C
vein is dissected and encircled. Cholecystectomy is performed and the cystic duct is marked for further transcystic manipulation. Subsequently, the attention is directed towards the hepatoduodenal ligament, where a complete lymphadenectomy is carried out. This surgical maneuver has an oncological purpose and is also helpful for the identification of anatomical variations (Fig. 3). The hepatic pedicle is encircled for the eventual need of a Pringle maneuver during liver partition. Then, an aggressive clean-up of the hepatic lesions in the
ACCEPTED MANUSCRIPT FLR (segments IV and I) is carried out, putting emphasis on not compromising the inflow or outflow of these segments (Fig. 4). Before starting the parenchymal transection, the vascular inflow and outflow of segments I and IV (that will represent the FLR) should be assessed with IOUS after clamping the right
RI PT
portal vein (RPV). Once a proper vascularization is certified, the RPV is sectioned (Fig. 5) and liver partition is carried out through the Cantlie’s line. Cavitron ultrasonic surgical aspirator in combination with the harmonic scalpel and cautery is used for parenchymal
SC
partition. The anterior and posterior right hepatic pedicle branches are isolated and encircled with silks or vessel loops for a better identification during the second stage (Fig. 6). During
M AN U
this step, it is important to prevent right hepatic artery injuries because it is the only vascular inflow of this hemi-liver. Careful control of the haemostasis is performed with Argon been, sutures and haemostatic agents.
Once it is certified that the ALPPS is technically feasible, the resection of the left lateral
TE D
segment due to high tumor load can be carried out (Fig. 7). The parenchymal transection line is marked 1 cm to the left of the falciform ligament in order to preserve segment IV vascular and biliary pedicles. The left lateral segment pedicle is dissected and ligated inside the
EP
umbilical plate. The ligament of Arantius is subsequently divided, and the confluence of the
AC C
middle and left hepatic veins isolated. Finally, the left hepatic vein is sutured isolating the left lateral segment from segment IV. At this point an IOUS is performed in order to ensure adequate inflow and outflow of the FLR. In order to detect biliary fistulas, a transcystic hydraulic test and cholangiography are routinely performed. To simplify the second stage, a plastic sheath is placed between the cut surfaces. Two drains are situated in the transection line and the right sub-phrenic space.
ACCEPTED MANUSCRIPT Stage 2 During postoperative day 6, a volumetric MDCT or MR of the FLR (segments IV and I) is performed in order to confirm liver hypertrophy and a tumor-free FLR. If the patient is in good condition and volumetric analyses showed a sufficient FLR hypertrophy, the
RI PT
completion surgery is scheduled for the following day.
The previous incision is used to enter the abdominal cavity. After releasing lax adhesions, the plastic sheath is removed and sent for microbiological analyses. An IOUS is performed in the
SC
FLR to certify a patent hepatic artery and portal vein. The anterior and posterior right pedicles that were encircled during stage 1 are recognized and ligated. The right hepatic vein
M AN U
is divided and sutured in a running fashion and the right hepatectomy is completed (Fig. 8). At the end of the procedure, a hydraulic test and cholangiography whenever possible is recommended to certify the absence of bile leaks.
TE D
DISCUSSION
Major liver resections continue to be associated with substantial morbidity and mortality particularly related with PHLF. Portal vein occlusion remains the gold standard technique to
EP
guarantee a sufficient FLR. However, patients with diabetes or severe sinusoidal injury (common situation in this population of patients) can be associated with impaired initial
AC C
growth of the FLR 17. Up to 40% of patients are not candidates for surgical resection, either because of tumor progression or insufficient FLR hypertrophy. Embolization of segment IV portal branches carries a considerable risk of accidental thrombosis or injury of the left portal vein, which vascularizes the FLR 18. The ALLPS approach has emerged as a new surgical strategy to increase resectability in patients with locally advanced oncological disease by a rapid FLR hypertrophy. Schnitzbauer et al13 described the initial multicentric German experience with the ALPPS technique in 25 patients with primary or metastatic liver tumors,
ACCEPTED MANUSCRIPT using the left lateral segments as part of the FLR. However, only patients with a tumor-free left lateral segment were included in the study. In our experience we have included patients with multiple bilobar disease, to whom we performed the resection (clean-up) of those lesions in the left lateral segment or the right posterior segments (VI and VII) as part of the
RI PT
FLR16.
Recently Gauzolino et al.19 presented different technical variations of the ALPPS approach, including the “left ALPPS”, the “right ALPPS” and the so-called “rescue ALPPS” in patients
SC
with failed PVE. However, there are no reports regarding the complete resection of segments II and III as an extreme clean-up of the FLR when performing a right hepatectomy during
M AN U
ALPPS. In this situation, only segments I and IV comprise the FLR. In the present manuscript we highlighted the technical aspects that we believe are important to safely perform this original variation of the ALPPS approach. Regarding the particular technical aspect of using a plastic sheath to minimize adhesions, the main disadvantage is that the
TE D
patient might still require a reoperation to remove this foreign body if the second stage cannot be performed. With this in mind, other authors have reported the use of absorbable material with favourable results20. To date we have treated 29 patients with the ALPPS approach, and
EP
in two cases we used the technique described in the present manuscript. Both patients suffered from colorectal liver metastases and were males of 69 and 77 years-old respectively.
AC C
During the postoperative period, both experienced a mild elevation of the bilirubin levels that recovered before 72 hs after the second stage. None of the patients suffered PHLF but one of them developed pleural effusion, acute renal insufficiency and inguinal hematoma due to a dialysis catheter that prolonged the hospital stay. Both patients were discharged fully recovered at 15 and 43 days after the first stage procedure. At follow-up, one patient is disease-free seven months after surgery and the other patient died from brain metastases five months after the procedure.
ACCEPTED MANUSCRIPT Given the fact that the ALPPS approach is a very complex and challenging two-stage procedure, it must be taken into account that it should be undertaken only by hepatobiliary specialists at high-volume centers.
RI PT
REFERENCES
1. Kavolius J, Fong Y, Blumgart LH. Surgical resection of metastatic liver tumors. Surg. Oncol. Clin.
SC
North Am. 1996;5:337.
2. Adam R, Laurent A, Azoulay D, et al. Two- stage hepatectomy: A planned strategy to treat
M AN U
irresectable liver tumors. Ann Surg. 2000;232:777–85.
3. D’Angelica M, Brennan MF, Fortner JG, et al. Ninety-six five-year survivors after liver resection for metastatic colorectal cancer. J. Am. Coll. Surg. 1997;185:554.
4. Liu H, Zhu S. Present status and future perspectives of preoperative portal vein embolization. Am J Surg. 2009;197:686–690.
TE D
5. Charnsangavej C, Clary B, Fong Y, et al. Selection of patients for resection of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol. 2006;13(10):1261-8. 6. Chun YS, Vauthey JN. Extending the frontiers of resectability in advanced colorectal cancer. Eur J
EP
Surg Oncol. 2007;33(2):52-8.
AC C
7. Nordlinger B, Van Cutsem E, Gruenberger T, et al. Combination of surgery and chemotherapy and the role of targeted agents in the treatment of patients with colorectal liver metastases: recommendations from an expert panel. Ann Oncol. 2009;20(6):985-92. 8. Wolf PS, Park JO, Bao F, et al. Preoperative chemotherapy and the risk of hepatotoxicity and morbidity after liver resection for metastatic colorectal cancer: a single institution experience. J Am Coll Surg. 2013;216(1):41-9. 9. Kishi Y, Abdalla EK, Chun YS, et al. Three Hundred and One Consecutive Extended Right Hepatectomies: Evaluation of Outcome Based on Systematic Liver Volumetry. Ann Surg. 2009;250 (4):540-548.
ACCEPTED MANUSCRIPT 10. Abulkhir A, Limongelli P, Healey AJ et al. Preoperative portal vein embolization for major liver resection: a meta-analysis. Ann Surg. 2008;247:49–57. 11. Hemming AW, Reed AI, Howard RJ et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg. 2003;237:686–691.
RI PT
12. Mueller L, Hillert C, Möller L, et al. Major hepatectomy for colorectal metastases: is preoperative portal occlusion an oncolog- ical risk factor? Ann Surg Oncol. 2008;15(7):1908–17.
13. Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portal vein ligation combined with in situ
resec- tion in small-for-size settings. Ann Surg. 2012;255:405–14.
SC
splitting induces rapid left lateral liver lobe hypertrophy enabling two-staged extended right hepatic
M AN U
14. de Santibañes E, Clavien PA. Playing Play-Doh to prevent post- operative liver failure: the “ALPPS” approach. Ann Surg. 2012;255(3):415–7.
15. Donati M, Stavrou GA, Basile F, et al. Combination of in situ split and portal ligation: lights and shadows of a new surgical procedure. Ann Surg. 2012;256(3):e11–2. author reply e16–9. 16. Alvarez FA, Ardiles V, Sanchez Claria R, et al. Associating Liver Partition and Portal Vein
TE D
Ligation for Staged Hepatectomy (ALPPS): Tips and Tricks. J Gastrointest Surg. 2013 Apr;17(4):814-21.
17. Shindoh J, Truty MJ, Aloia TA, et al. Kinetic growth rate after portal vein embolization predicts
EP
posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant. J Am Coll Surg. 2013 Feb;216(2):201-9.
AC C
18. Loos M, Friess H. Is there new hope for patients with marginally resectable liver malignancies. World J Gastrointest Surg. 2012 Jul 27;4(7):163-5. 19. Gauzolino R, Castagnet M, Blanleuil ML, Richer JP. The ALPPS technique for bilateral colorectal metastases: three "variations on a theme". Updates Surg. 2013;65(2):141-8. 20. Schnitzbauer AA, Lang SA. ALPPS: Response to letter to the editor. Ann Surg. 2012;256(3):e167.
ACCEPTED MANUSCRIPT FIGURE LEGENDS
Figure 1: Surgical exploration demonstrating a liver with an extensive tumor load. Metastatic lesions are presents in all segments of the liver. Segment IV clean-up is planned in order to become part of
RI PT
the future liver remnant (dotted lines). (Drawing by coauthor Fanny Rodriguez Santos.) Figure 2: A. Preoperative liver volumetric MR in a 77-year-old patient with multiple bilateral colorectal liver metastases who received 6 cycles of chemotherapy. B. The estimated future liver remnant volume (FLR) including segments I and IV was 305 ml. The FLR represented only 20% of
SC
the total liver volume.
Figure 3: Portal pedicle lymphadenectomy during the first stage of ALPPS. A black silk is around the
M AN U
portal triad. The left portal vein is encircled with a blue vessel loop, the right hepatic artery with a red vessel loop and the left hepatic artery with a white vessel loop. Bile duct is pointed with an asterisk and the cystic duct with a black arrow.
Figure 4: Atypical resections (clean-up) of metastatic lesions in segments IVa and IVb.
TE D
Figure 5: The right portal vein is divided between clamps and sutured in a running fashion. Figure 6: Liver partition at the level of the Cantlie’s line using the hanging maneuver. The right hepatic vein (white arrowhead) as well as the anterior and posterior right hepatic pedicles are
EP
encircled with light blue ties.
Figure 7: Left lateral resection due to extensive metastatic compromise. (Drawing by coauthor Fanny
AC C
Rodriguez Santos.)
Figure 8: Intraoperative photo during the second stage of ALPPS. A 152% hypertrophy was demonstrated on preoperative volumetric analysis and observed intraoperatively. The hypertrophied liver remnant (771 ml) is seen after the resection of the disease hemi-liver.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
