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The First Outstanding 50 Years of “Università Politecnica delle Marche” pp 265–283Cite as

Advances in Hepatobiliary Surgery: The Ancona’s Experience with ALPPS Procedure for Extended Liver Resections

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Abstract

Aim. To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique. Methods. Patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow a standard hepatic resection were prospectively assessed for the ALPPS procedure. Results. From January 2013 until December 2018, 25 patients were considered for the ALPPS procedure at our institution. Five patients were judged intraoperatively not to be suitable for the surgical therapy and two patients underwent the first step of the ALPPS procedure but did not complete the second step. The ALPPS procedure was completed in 18 patients whose median age was 61.9 ± 6.5 years. Indications for surgical resection were metastases from colorectal cancer in 4 cases, perihilar cholangiocarcinoma in 4 cases, intrahepatic cholangiocarcinoma in 4 cases, hepatocellular carcinoma in 4 cases and gallbladder carcinoma in 2 cases. The calculated FLR volume was 302.5 ± 88.9 mL (22.6 ± 5.2% of the total liver volume) before ALPPS-1 and 514.4 ± 130.0 mL (31.9 ± 6.0%) before ALLPS-2 (p < 0.001). After a mean interval of 10.6 ± 2.6 days between the two procedures, the increase in FLR was 76.4 ± 39.6% (p < 0.001). Sixteen (88.9%) out of 18 patients required one or more additional interventions during the first surgical step; these consisted in 7 Roux-en-Y hepaticojejunostomy, 3 wedge resections of a residual tumor in the FLR and 10 cholecystectomies. The median hospital stay was 23 (IQR: 22–27.7) days. In-hospital mortality occurred in 3 (16.7%) patients for postoperative liver failure (2 cases) and multiple organ failure; 10 (55.5%) out of 18 patients experienced a grade III or above surgical complication according to Clavien-Dindo classification. After a median follow-up of 26.6 (IQR: 4.5–40.0) months, the 1- and 3-years overall survival rates were 69.4% and 47.6%, respectively. The 1- and 3-years recurrence-free survival rates were 70.7% and 53.0%, respectively. Conclusion. The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors, improving survival in these patients. The postoperative morbidity in our series was high in accordance with the data from the international ALPPS registry.

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Abbreviations

FLR:

Future liver remnant

PVE:

Portal embolization

PVL:

Portal vein ligation

PVO:

Portal vein occlusion

ALPPS:

Associating Liver Partition and Portal vein Ligation for Staged hepatectomy

TLV:

Total liver volume

TuV:

Tumor volume

pCCA:

Perihilar cholangiocarcinoma

iCCA:

Intrahepatic cholangiocarcinoma

GBC:

Gallbladder carcinoma

HCC:

Hepatocellular carcinoma

CEA:

Carcinoembryonic antigen

α-FP:

Serum alphafetoprotein

BMI:

Body mass index

ALTPS:

Associating Liver Tourniquet and Partial ligation for Staged hepatectomy

DC:

Dindo-Clavien classification

CCI:

Comprehensive Complication Index

References

  1. Adams RB, Aloia TA, Loyer E, Pawlik TM, Taouli B, Vauthey JN et al (2013) Selection for hepatic resection of colorectal liver metastases: expert consensus statement. HPB: Off J Int Hepato Pancreato Biliary Assoc 15(2):91–103. https://doi.org/10.1111/j.1477-2574.2012.00557.x. PubMed PMID: 23297719; PubMed Central PMCID: PMC3719914

  2. Farges O, Belghiti J, Kianmanesh R, Regimbeau JM, Santoro R, Vilgrain V et al (2003) Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg 237(2):208–217. https://doi.org/10.1097/01.sla.0000048447.16651.7b. PubMed PMID: 12560779; PubMed Central PMCID: PMC1522143

  3. Kokudo N, Tada K, Seki M, Ohta H, Azekura K, Ueno M et al (2001) Proliferative activity of intrahepatic colorectal metastases after preoperative hemihepatic portal vein embolization. Hepatology 34(2):267–272. https://doi.org/10.1053/jhep.2001.26513 PubMed PMID: 11481611

    Article  Google Scholar 

  4. Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA et al (2012) 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 255(3):405–414

    Article  Google Scholar 

  5. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213. PubMed PMID: 15273542; PubMed Central PMCID: PMC1360123

    Google Scholar 

  6. Schindl MJ, Redhead DN, Fearon KC, Garden OJ, Wigmore SJ, Edinburgh Liver S et al (2005) The value of residual liver volume as a predictor of hepatic dysfunction and infection after major liver resection. Gut 54(2):289–296. https://doi.org/10.1136/gut.2004.046524 PubMed PMID: 15647196; PubMed Central PMCID: PMC1774834

    Article  Google Scholar 

  7. Reiner CS, Karlo C, Petrowsky H, Marincek B, Weishaupt D, Frauenfelder T (2009) Preoperative liver volumetry: how does the slice thickness influence the multidetector computed tomography- and magnetic resonance-liver volume measurements? J Comput Assist Tomogr 33(3):390–397. https://doi.org/10.1097/RCT.0b013e3181806c29 PubMed PMID: 19478632

    Article  Google Scholar 

  8. Zappa M, Dondero F, Sibert A, Vullierme MP, Belghiti J, Vilgrain V (2009) Liver regeneration at day 7 after right hepatectomy: global and segmental volumetric analysis by using CT. Radiology 252(2):426–432. https://doi.org/10.1148/radiol.2522080922 DOI: 10.1148/radiol.2523080922. PubMed PMID: 19703882

    Article  Google Scholar 

  9. Donati M, Basile F, Oldhafer KJ (2015) Present status and future perspectives of ALPPS (associating liver partition and portal vein ligation for staged hepatectomy). Futur Oncol 11(16):2255–2258. https://doi.org/10.2217/fon.15.145 PubMed PMID: 26260803

    Article  Google Scholar 

  10. Jacobson BF, Louw S, Buller H, Mer M, de Jong PR, Rowji P et al (2013) Venous thromboembolism: prophylactic and therapeutic practice guideline. S Afr Med J (Suid-Afrikaanse tydskrif vir geneeskunde) 103(4 Pt 2):261–267. https://doi.org/10.7196/samj.6706. PubMed PMID: 23547704

  11. Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D et al (2005) The “50–50 criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg 242(6):824–828, discussion 8–9. PubMed PMID: 16327492; PubMed Central PMCID: PMC1409891

    Article  Google Scholar 

  12. Zhang GQ, Zhang ZW, Lau WY, Chen XP (2014) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): a new strategy to increase resectability in liver surgery. Int J Surg (London, England) 12(5):437–441. Epub 2014/04/08. https://doi.org/10.1016/j.ijsu.2014.03.009. PubMed PMID: 24704086

  13. Vennarecci G, Laurenzi A, Levi Sandri GB, Busi Rizzi E, Cristofaro M, Montalbano M et al (2014) The ALPPS procedure for hepatocellular carcinoma. Eur J Surg Oncol: J Eur Soc Surg Oncol Br Assoc Surg Oncol 40(8):982–988. Epub 2014/04/29. https://doi.org/10.1016/j.ejso.2014.04.002. PubMed PMID: 24767805

  14. Liu H, Zhu S (2009) Present status and future perspectives of preoperative portal vein embolization. Am J Surg 197(5):686–690. https://doi.org/10.1016/j.amjsurg.2008.04.022 PubMed PMID: 19249737

    Article  Google Scholar 

  15. Aussilhou B, Lesurtel M, Sauvanet A, Farges O, Dokmak S, Goasguen N et al (2008) Right portal vein ligation is as efficient as portal vein embolization to induce hypertrophy of the left liver remnant. J Gastrointest Surg: Off J Soc Surg Aliment Tract 12(2):297–303. Epub 2007/12/07. https://doi.org/10.1007/s11605-007-0410-x. PubMed PMID: 18060468

  16. Tschuor C, Croome KP, Sergeant G, Cano V, Schadde E, Ardiles V et al (2013) Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion—an extension of the ALPPS approach. Eur J Surg Oncol: J Eur Soc Surg Oncol Br Assoc Surg Oncol 39(11):1230–1235. Epub 2013/09/03. https://doi.org/10.1016/j.ejso.2013.08.009. PubMed PMID: 23994139

  17. Alvarez FA, Ardiles V, Sanchez Claria R, Pekolj J, de Santibañes E (2013) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): tips and tricks. J Gastrointest Surg 17(4):814–821

    Article  Google Scholar 

  18. Nadalin S, Capobianco I, Li J, Girotti P, Königsrainer I, Königsrainer A (2014) Indications and limits for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) lessons learned from 15 cases at a single centre. Z Gastroenterol 52(1):35–42

    Google Scholar 

  19. Schadde E, Ardiles V, Robles-Campos R, Malago M, Machado M, Hernandez-Alejandro R et al (2014) Early survival and safety of ALPPS: first report of the international ALPPS registry. Ann Surg 260(5):829–838. https://doi.org/10.1097/SLA.0000000000000947. PubMed PMID: 25379854

  20. Higuchi R, Yamamoto M (2014) Indications for portal vein embolization in perihilar cholangiocarcinoma. J Hepato-Biliary-Pancreat Sci 21(8):542–549. https://doi.org/10.1002/jhbp.77. PubMed PMID: 24520045

  21. Cavaness KM, Doyle MBM, Lin Y, Maynard E, Chapman WC (2013) Using ALPPS to induce rapid liver hypertrophy in a patient with hepatic fibrosis and portal vein thrombosis. J Gastrointest Surg 17(1):207–212

    Google Scholar 

  22. Ding X, Carrasco-Avino G, Thung SN, Roayaie S (2013) A two-step right hepatic lobectomy with portal vein ligation for large hepatocellular carcinoma: rapid induction of left-lobe regeneration and clinicopathologic correlation. Semin Liver Dis 33(3):293–297. Epub 2013/08/15. https://doi.org/10.1055/s-0033-1351786. PubMed PMID: 23943109

  23. Torres OJ, Moraes-Junior JM, Lima e Lima NC, Moraes AM (2012) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): a new approach in liver resections. Arquivos brasileiros de cirurgia digestiva: ABCD = Braz Arch Dig Surg 25(4):290–292. Epub 2013/02/16. PubMed PMID: 23411931

    Google Scholar 

  24. Bjornsson B, Gasslander T, Sandstrom P (2013) In situ split of the liver when portal venous embolization fails to induce hypertrophy: a report of two cases. Case Rep Surg 2013:238675. Epub 2014/01/03. https://doi.org/10.1155/2013/238675. PubMed PMID: 24383035; PubMed Central PMCID: PMCPMC3871496

  25. Oldhafer KJ, Donati M, Jenner RM, Stang A, Stavrou GA (2014) ALPPS for patients with colorectal liver metastases: effective liver hypertrophy, but early tumor recurrence. World J Surg 38(6):1504–1509. Epub 2013/12/12. https://doi.org/10.1007/s00268-013-2401-2. PubMed PMID: 24326456

  26. Troja A, Khatib-Chahidi K, El-Sourani N, Antolovic D, Raab HR (2014) ALPPS and similar resection procedures in treating extensive hepatic metastases: our own experiences and critical discussion. Int J Surg (London, England) 12(9):1020–1022. Epub 2014/07/22. https://doi.org/10.1016/j.ijsu.2014.07.006. PubMed PMID: 25043935

  27. Ratti F, Cipriani F, Gagliano A, Catena M, Paganelli M, Aldrighetti L (2014) Defining indications to ALPPS procedure: technical aspects and open issues. Updat Surg 66(1):41–49. Epub 2013/12/18. https://doi.org/10.1007/s13304-013-0243-y. PubMed PMID: 24343420

  28. MacHado MAC, Makdissi FF, Surjan RC (2012) Totally laparoscopic ALPPS is feasible and may be worthwhile. Ann Surg 256(3)

    Google Scholar 

  29. Chan A, Chung PHY, Poon RTP (2014) Little girl who conquered the “ALPPS”. World J Gastroenterol 29:10208–10211

    Google Scholar 

  30. Schadde E, Schnitzbauer AA, Tschuor C, Raptis DA, Bechstein WO, Clavien PA (2015) Systematic review and meta-analysis of feasibility, safety, and efficacy of a novel procedure: associating liver partition and portal vein ligation for staged hepatectomy. Ann Surg Oncol 22(9):3109–3120. Epub 2014/12/03. https://doi.org/10.1245/s10434-014-4213-5. PubMed PMID: 25448799

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Authors and Affiliations

  1. Division of Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, A.O.U. “Ospedali Riuniti”, Polytechnic University of Marche, Via Conca 71, 60129, Ancona, Italy

    Federico Mocchegiani & Marco Vivarelli

Authors
  1. Federico Mocchegiani
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  2. Marco Vivarelli
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Corresponding author

Correspondence to Federico Mocchegiani .

Editor information

Editors and Affiliations

  1. Department of Information Engineering (DII), Marche Polytechnic University, Ancona, Italy

    Sauro Longhi

  2. Department of Information Engineering (DII), Marche Polytechnic University, Ancona, Italy

    Andrea Monteriù

  3. Department of Information Engineering (DII), Marche Polytechnic University, Ancona, Italy

    Alessandro Freddi

  4. Department of Agricultural, Food and Environmental Sciences (D3A), Marche Polytechnic University, Ancona, Italy

    Lucia Aquilanti

  5. Ospedali Riuniti di Ancona, Ancona, Italy

    Maria Gabriella Ceravolo

  6. Department of Life and Environmental Sciences (DISVA), Marche Polytechnic University, Ancona, Italy

    Oliana Carnevali

  7. Department of Life and Environmental Sciences (DISVA), Marche Polytechnic University, Ancona, Italy

    Mario Giordano

  8. Ospedali Riuniti di Ancona, Ancona, Italy

    Gianluca Moroncini

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Mocchegiani, F., Vivarelli, M. (2020). Advances in Hepatobiliary Surgery: The Ancona’s Experience with ALPPS Procedure for Extended Liver Resections. In: Longhi, S., et al. The First Outstanding 50 Years of “Università Politecnica delle Marche”. Springer, Cham. https://doi.org/10.1007/978-3-030-33832-9_18

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  • DOI: https://doi.org/10.1007/978-3-030-33832-9_18

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