Background. ALPPS is found to increase the resectability of primary and secondary liver malignancy at the advanced stage. The aim of the study was to verify the surgical and oncological outcome of ALPPS for intrahepatic cholangiocarcinoma (ICC). Methods. The study cohort was based on the ALPPS registry with patients from 31 international centers between August 2009 and January 2018. Propensity score matched patients receiving chemotherapy only were selected from the SEER database as controls for the survival analysis.
Objectives: To analyze long-term oncological outcome along with prognostic risk factors in a large cohort of patients with colorectal liver metastases (CRLM) undergoing ALPPS. Background: ALPPS is a two-stage hepatectomy variant that increases resection rates and R0 resection rates in patients with primarily unresectable CRLM as evidenced in a recent randomized controlled trial. Long-term oncologic results, however, are lacking. Methods: Cases in- and outside the International ALPPS Registry were collected and completed by direct contacts to ALPPS centers to secure a comprehensive cohort. Overall, cancer-specific (CSS), and recurrence-free (RFS) survivals were analyzed along with independent risk factors using Cox-regression analysis. Results: The cohort included 510 patients from 22 ALPPS centers over a 10-year period. Ninety-day mortality was 4.9% and median overall survival, CSS, and RFS were 39, 42, and 15 months, respectively. The median follow-up time was 38 months (95% confidence interval 32–43 months). Multivariate analysis identified tumor-characteristics (primary T4, right colon), biological features (K/N-RAS status), and response to chemotherapy (Response Evaluation Criteria in Solid Tumors) as independent predictors of CSS. Traditional factors such as size of metastases, uni versus bilobar involvement, and liver-first approach were not predictive. When hepatic recurrences after ALPPS was amenable to surgical/ablative treatment, median CSS was significantly superior compared to chemotherapy alone (56 vs 30 months, P < 0.001). Conclusions: This large cohort provides the first evidence that patients with primarily unresectable CRLM treated by ALPPS have not only low perioperative mortality, but achieve appealing long-term oncologic outcome especially those with favorable tumor biology and good response to chemotherapy.
Nontumoral portal vein thrombosis (PVT) is present at liver transplantation (LT) in 5-26% of cirrhotic patients, and is known to affect post LT outcomes. Up to 31% of patients who are found to have PVT at the time of LT, would have had PVT at the time of initial listing, but others develop PVT during the waiting period. Adequate screening and treatment of the PVT on the waiting list for LT is thus essential so that a portoportal anastomoses can be performed at the time of LT. Early PVT (Yerdel Grade I/II) can be usually managed by thrombectomy, whereas Grade III PVT may require a jump graft from the superior mesenteric vein to the graft PV. Complete portomesenteric thrombosis is a huge challenge, and sometimes a cause for denying a LT in these patients, with multivisceral transplant being the only alternative. The presence of spontaneous, or previously surgically created portosytemic shunts like the leinorenal shunt, may serve as a good inflow option (renoportal anastomosis) in these patients to establish a physiological reconstruction. Although challenging, good outcomes are possible in patients with complex PVT if the appropriate surgical technique is chosen to ensure portal inflow and resolution of PHT post LT. Nontumoral portal vein thrombosis (PVT)is present at liver transplantation (LT) in 5%-26% of cirrhotic patients [1]. Up to 31% of patients who are found to have PVT at the time of LT, would have had PVT at the time of initial listing, but others develop PVT during the waiting period. Thus, up to 50% of cases of PVT are still diagnosed intraoperatively, with potential harm to the patient due to the complexity of portal reconstruction [1]. Hence, screening, and management of the PVT during the waiting period is also important.After being considered an absolute contraindication for LT for a long time due to the high mortality associated with the procedure [2], recently, more patients with PVT are being accepted for LT, especially in experienced LT centers [3]. Initial studies reported worse post-LT outcomes in PVT patients compared to those without PVT, however, most studies published after the year 2000 have reported similar 1-year survival in both groups [3,4], provided an end to end porto-portal anastomoses can be achieved during LT, after clearance of the thrombus. This is usually possible in Grade I/II Yerdel PVT [5], but may be difficult in patients with diffuse (Grade III/IV Yerdel) PVT. Hence, the latter group of patients is still not considered for LT by most centers worldwide, given the inferior outcomes.Adequate portal inflow to the graft is the key factor that determines graft and patient survival after LT [6]. In addition to this, the new liver should also be able to alleviate the pre existing portal hypertension in the recipient, and for this a physiological re-direction of splanchnic blood into the new liver (graft) is essential [7]. This is sometimes not always possible in diffuse PVT, thus giving rise to problems of bleeding, mesenteric congestion and bowel ischemia after LT. This aspect h...
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