„In-situ-Split“- (ISS) Leberresektion: Neue Aspekte zu Technik und Indikation

Abstract

The combination of right portal vein ligation with complete parenchyma dissection ("in-situ split", ISS) for rapid hypertrophy induction of the left-lateral liver lobe is a novel strategy to convert primarily irresectable liver tumours into a resectable stage. Available data so far show a 60-80 % growth induction of the remnant liver within 7(- 9) days. Certainly, a novel concept that comprises two operations within a very short time period raises questions. Based on the very few literature reports that have been published so far, as well as our own experience, we here discuss technical issues such as the use of a plastic sheet on the resection margin, the possibility of laparoscopic dissection and the timing of the second operation. Moreover, aspects of the preoperative diagnostic work-up that is necessary are assessed. Finally, open questions, e.g., concerning the influence of preoperative chemotherapy and the use of ISS in patients with cirrhosis are evaluated. In summary, the assessment of chances and risks of this novel concept with regard to indication and technical issues helps to provide the potentially curative option of the "in-situ split" procedure to more patients with marginal or even irresectable liver tumours.

Indications and Limits for Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS). Lessons Learned from 15 Cases at a Single Centre

“…Two-stage hepatectomy a) with sequential removal of affected liver parenchyma [7], or b) combined with PVE [8,9], or c) combined with portal vein ligation (PVL) [10,11] 3. Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), also known as "in-situ split" (ISS) liver resection, which was originally developed by the Regensburg group [12] and first published in 2012 as a multicenter German experience [13]. The technical aspects and pitfalls of the procedure were recently reported by the groups in Regensburg [12,14], Buenos Aires [15] and Tübingen [16].…”

Associating liver partition and portal vein ligation for staged hepatectomy for Klatskin tumours:hinc sunt leones!

“…Potential application of ALPPS in patients with Klatskin tumours requiring extended liver resection has been recently proposed by Schlitt et al . in a young woman with a Klatskin tumour who according to traditional standards, was considered unresectable …”

“…This modality leaves considerable freedom in the strategy of resection during laparotomy and exploration. In this view, the proposed ‘three variations on the theme’ indicating the three potential transection planes make the strategy feasible independently from the anatomical side of resection (right or left). The surgeon can safely plan the second step, packing the future specimen in a plastic bag and draining the cholestatic biliary tree Delay of 7–10 days in removing the specimen does not affect the oncological radicality of the operation and increases safety of extended resection by reducing the impact of small‐for‐size syndrome. The second step allows the surgeon to check the hepatico‐jejunostomy on the side of the remnant liver and to control a possible bile leak. …”

“…The surgeon can safely plan the second step, packing the future specimen in a plastic bag and draining the cholestatic biliary tree …”

Did the International ALPPS Meeting 2015 Have an Impact on Daily Practice The Hamburg Barmbek Experience of 58 Cases

“…The first in-situ split procedure performed by Hans Schlitt in Regensburg in 2007 was adopted 10 years later as a new method to face extensive liver disease requiring staged procedures by many centers in Germany and worldwide [1][2][3][4][5][6][7][8][9][10][11][12][13].…”