Медицинская литература. Новинки

 

 

 

 

 

 

Двухэтапные резекции печени методом ALPPS: ближайшие и отдаленные результаты

Вы можете загрузить полный текст статьи в формате pdf

Цель. Оценка ближайших и отдаленных результатов двухэтапной резекции печени методом ALPPS. Материал и методы. В ретроспективный анализ включены 7 пациентов (средний возраст 62 года) с объемом интактной паренхимы печени (будущий остаток печени, Future Liver Remnant, FLR) 25%. Всем больным выполнили ALPPS с 2014 по 2021 г. Оба этапа ALPPS выполнены традиционным способом. Прирост интактной паренхимы на 6–8-е сутки после I этапа оценивали КТ-волюметрией. Анализировали основные операционные характеристики, частоту послеоперационных осложнений по Clavien–Dindo и ISGLS, время без прогрессирования и продолжительность жизни. Результаты. Медиана продолжительности I этапа ALPPS составила 250 мин, медиана кровопотери – 600 мл, II этапа – 210 мин и 300 мл. Медиана FLR до и после I этапа ALPPS составила 15,3 и 31,6%. Медиана гипертрофии FLR после I этапа ALPPS составила 123%. Медиана интервала между I и II этапами ALPPS составила 10 сут. Всем больным выполнена резекция R0. Частота послеоперационных осложнений после I этапа ALPPS составила 14,3% (Clavien–Dindo I), после II этапа – 57,1% (Clavien–Dindo III–V). Летальность в течение 90 дней после II этапа ALPPS составила 14,3%. Медиана наблюдения – 25 мес. Медиана времени без прогрессирования у 6 больных, оперированных по поводу метастазов колоректального рака, составила 6 мес, медиана продолжительности жизни – 31 мес. Пациент, перенесший ALPPS по поводу гепатоцеллюлярного рака, жив, признаков прогрессирования болезни нет. Заключение. ALPPS обеспечивает быстрый и более чем двукратный прирост FLR и увеличивает вероятность выполнения резекции R0 у больных с исходно нерезектабельными первичными и вторичными опухолями печени. Однако ближайшие результаты ALPPS неудовлетворительные. Показания к операции предельно спорные ввиду развития лекарственных методов лечения, методов абляции и радиотерапии.

Ключевые слова:
печень, двухэтапная резекция, ALPPS, синхронные метастазы, колоректальный рак, гепатоцеллюлярный рак, FLR, in situ split

Литература:
1. Li J., Girotti P., Konigsrainer I., Ladurner R., Konigsrainer A., Nadalin S. ALPPS in right trisectionectomy: a safe procedure to avoid postoperative liver failure? J. Gastrointest. Surg. 2013; 17 (5): 956-961. https://doi.org/10.1007/s11605-012-2132-y
2. Ratti F., Cipriani F., Gagliano A., Catena M., Paganelli M., Aldrighetti L. Defining indications to ALPPS procedure: technical aspects and open issues. Updates Surg. 2014; 66 (1): 41-49. https://doi.org/10.1007/s13304-013-0243-y
3. Cai X., Tong Y., Yu H., Liang X., Wang Y., Liang Y., Li Z., Peng S., Lau W.Y. The ALPPS in the treatment of hepatitis B-related hepatocellular carcinoma with cirrhosis: a single-center study and literature review. Surg. Innov. 2017; 24 (4): 358-364. https://doi.org/10.1177/1553350617697187
4. Pandanaboyana S., Bell R., Hidalgo E., Toogood G., Prasad K.R., Bartlett A., Lodge J.P. A systematic review and meta-analysis of portal vein ligation versus portal vein embolization for elective liver resection. Surgery. 2015; 157 (4): 690-698. https://doi.org/10.1016/j.surg.2014.12.009
5. Aussilhou B., Lesurtel M., Sauvanet A., Farges O., Dokmak S., Goasguen N., Sibert A., Vilgrain V., Belghiti J. Right portal vein ligation is as efficient as portal vein embolization to induce hypertrophy of the left liver remnant. J. Gastrointest. Surg. 2008; 12 (2): 297-303. https://doi.org/10.1007/s11605-007-0410-x
6. Capussotti L., Muratore A., Baracchi F., Lelong B., Ferrero A., Regge D., Delpero J.R. Portal vein ligation as an efficient method of increasing the future liver remnant volume in the surgical treatment of colorectal metastases. Arch. Surg. 2008; 143 (10): 978-982; discussion 982. https://doi.org/10.1001/archsurg.143.10.978
7. Broering D.C., Hillert C., Krupski G., Fischer L., Mueller L., Achilles E.G., Schulte am Esch J., Rogiers X. Portal vein embolization vs. portal vein ligation for induction of hypertrophy of the future liver remnant. J. Gastrointest. Surg. 2002; 6 (6): 905-913; discussion 913. https://doi.org/10.1016/s1091-255x(02)00122-1
8. Shindoh J., Truty M.J., Aloia T.A., Curley S.A., Zimmitti G., Huang S.Y., Mahvash A., Gupta S., Wallace M.J., Vauthey J.N. Kinetic growth rate after portal vein embolization predicts posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant. J. Am. Coll. Surg. 2013; 216 (2): 201-209. https://doi.org/10.1016/j.jamcollsurg.2012.10.018
9. Schnitzbauer A.A., Lang S.A., Goessmann H., Nadalin S., Baumgart J., Farkas S.A., Fichtner-Feigl S., Lorf T., Goralcyk A., Horbelt R., Kroemer A., Loss M., Rummele P., Scherer M.N., Padberg W., Konigsrainer A., Lang H., Obed A., Schlitt H.J. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann. Surg. 2012; 255 (3): 405-414. https://doi.org/10.1097/SLA.0b013e31824856f5
10. Shindoh J., Vauthey J.N., Zimmitti G., Curley S.A., Huang S.Y., Mahvash A., Gupta S., Wallace M.J., Aloia T.A. Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach. J. Am. Coll. Surg. 2013; 217 (1): 126-133; discussion 133-134. https://doi.org/10.1016/j.jamcollsurg.2013.03.004
11. Schadde E., Ardiles V., Robles-Campos R., Malago M., Machado M., Hernandez-Alejandro R., Soubrane O., Schnitzbauer A.A., Raptis D., Tschuor C., Petrowsky H., De Santibanes E., Clavien P.A. ALPPS Registry Group. Early survival and safety of ALPPS: first report of the International ALPPS Registry. Ann. Surg. 2014; 260 (5): 829-836; discussion 836-838. https://doi.org/10.1097/SLA.0000000000000947
12. Oldhafer K.J., Donati M., Jenner R.M., Stang A., Stavrou G.A. ALPPS for patients with colorectal liver metastases: effective liver hypertrophy, but early tumor recurrence. World J. Surg. 2014; 38 (6): 1504-1509. https://doi.org/10.1007/s00268-013-2401-2
13. Adam R., Imai K., Castro Benitez C., Allard M.A., Vibert E., Sa Cunha A., Cherqui D., Baba H., Castaing D. Outcome after associating liver partition and portal vein ligation for staged hepatectomy and conventional two-stage hepatectomy for colorectal liver metastases. Br. J. Surg. 2016; 103 (11): 1521- 1529. https://doi.org/10.1002/bjs.10256
14. Eisenhauer E.A., Therasse P., Bogaerts J., Schwartz L.H., Sargent D., Ford R., Dancey J., Arbuck S., Gwyther S., Mooney M., Rubinstein L., Shankar L., Dodd L., Kaplan R., Lacombe D., Verweij J. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur. J. Cancer. 2009; 45 (2): 228-247. https://doi.org/10.1016/j.ejca.2008.10.026
15. Clavien P.A., Barkun J., de Oliveira M.L., Vauthey J.N., Dindo D., Schulick R.D., de Santibanes E., Pekolj J., Slankamenac K., Bassi C., Graf R., Vonlanthen R., Padbury R., Cameron J.L., Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann. Surg. 2009; 250 (2): 187-196. https://doi.org/10.1097/SLA.0b013e3181b13ca2
16. Koch M., Garden O.J., Padbury R., Rahbari N.N., Adam R., Capussotti L., Fan S.T., Yokoyama Y., Crawford M., Makuuchi M., Christophi C., Banting S., Brooke-Smith M., Usatoff V., Nagino M., Maddern G., Hugh T.J., Vauthey J.N., Greig P., Rees M., Nimura Y., Figueras J., DeMatteo R.P., Buchler M.W., Weitz J. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery. 2011; 149 (5): 680-688. https://doi.org/10.1016/j.surg.2010.12.002
17. Rahbari N.N., Garden O.J., Padbury R., Brooke-Smith M., Crawford M., Adam R., Koch M., Makuuchi M., Dematteo R.P., Christophi C., Banting S., Usatoff V., Nagino M., Maddern G., Hugh T.J., Vauthey J.N., Greig P., Rees M., Yokoyama Y., Fan S.T., Nimura Y., Figueras J., Capussotti L., Buchler M.W., Weitz J. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery. 2011; 149 (5): 713-724. https://doi.org/10.1016/j.surg.2010.10.001
18. Truant S. Enlarged and uncommon indications for ALPPS-where do we stand? Hepatobiliary Surg. Nutr. 2022; 11 (5): 743-745. https://doi.org/10.21037/hbsn-22-371
19. Petrowsky H., Linecker M., Raptis D.A., Kuemmerli C., Fritsch R., Kirimker O.E., Balci D., Ratti F., Aldrighetti L., Voskanyan S., Tomassini F., Troisi R.I., Bednarsch J., Lurje G., Fard-Aghaie M.H., Reese T., Oldhafer K.J., Ghamarnejad O., Mehrabi A., Abraham M.E.T., Truant S., Pruvot F.R., Hoti E., Kambakamba P., Capobianco I., Nadalin S., Fernandes E.S.M., Kron P., Lodge P., Olthof P.B., van Gulik T., Castro-Benitez C., Adam R., Machado M.A., Teutsch M., Li J., Scherer M.N., Schlitt H.J., Ardiles V., de Santibanes E., Brusadin R., Lopez-Lopez V., Robles-Campos R., Malago M., Hernandez-Alejandro R., Clavien P.A. First long-term oncologic results of the ALPPS procedure in a large cohort of patients with colorectal liver metastases. Ann. Surg. 2020; 272 (5): 793-800. https://doi.org/10.1097/SLA.0000000000004330
20. Sandstrom P., Rosok B.I., Sparrelid E., Larsen P.N., Larsson A.L., Lindell G., Schultz N.A., Bjornbeth B.A., Isaksson B., Rizell M., Bjornsson B. 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). Ann. Surg. 2018; 267 (5): 833-840. https://doi.org/10.1097/SLA.0000000000002511
21. Hernandez-Alejandro R., Bertens K.A., Pineda-Solis K., Croome K.P. Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases? Surgery. 2015; 157 (2): 194-201. https://doi.org/10.1016/j.surg.2014.08.041

ALPPS technique for two-stage liver resections: immediate and long-term results

Aim. To evaluate the immediate and long-term results of two-stage liver resection performed by means of ALPPS technique. Materials and methods. The retrospective analysis involved 7 patients (mean age 62 years) with intact liver parenchyma volume (Future Liver Remnant, FLR) 25%. All patients underwent ALPPS from 2014 to 2021. Both stages of ALPPS were performed in the traditional way. The increment of intact parenchyma on days 6–8 after stage I was evaluated by CT volumetry. The main operative characteristics, incidence of postoperative complications according to Clavien-Dindo and ISGLS, time without progression and life expectancy were analyzed. Results. The median duration of ALPPS stage I was 250 min, median blood loss was 600 ml, and stage II – 210 min and 300 ml, correspondingly. The median FLR before and after ALPPS stage I was 15.3% and 31.6%. The median FLR hypertrophy after ALPPS stage I accounted for 123%. The median interval between stage I and II of ALPPS was 10 days. All patients underwent R0 resection. The incidence of postoperative complications after ALPPS stage I was 14.3% (Clavien–Dindo I), after stage II – 57.1% (Clavien–Dindo III–V). The mortality rate within 90 days after ALPPS stage II accounted for 14.3%. Median follow-up was 25 months. The median time without progression in 6 patients operated for colorectal cancer metastases was 6 months, the median life expectancy was 31 months. The patient who underwent ALPPS for hepatocellular carcinoma is alive, no signs of disease progression have been detected. Conclusion. ALPPS provides a rapid and more than two-fold growth in FLR and increases the likelihood of R0 resection in patients with initially unresectable primary and secondary liver tumors. However, the immediate results of ALPPS are unsatisfactory. The indications for surgery are extremely controversial due to the development of drug therapies, ablation techniques and radiotherapy.

Keywords:
liver, two-stage resection, ALPPS, synchronous metastases, colorectal cancer, hepatocellular cancer, FLR, in situ split