Is the extent of functional liver remnant increase truly “functional”? A single-institution case series of patients with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)

Abstract

Introduction: Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) aims to induce rapid hypertrophy of the future liver remnant (FLR) to reduce the risk of post-hepatectomy liver failure (PHLF). However, volumetric increase does not correspond to functional increase. This is a novel study which aims to compare the increase in standardized FLR (sFLR) vs. indocyanine green retention at 15 minutes (ICG-R15). Material and methods: This is a retrospective case series of patients who underwent ALPPS between May 2015 and January 2022. Primary outcomes were sFLR and ICG-R15. Secondary outcomes were incidence of PHLF, morbidity, recurrence, overall survival (OS) and disease-free survival (DFS). Results: There were 10 patients with median age of 60.5 years (range 29-69). Most patients had adenocarcinoma secondary to colorectal origin (80%). There were 7 patients who received neoadjuvant chemotherapy [median 6 cycles (range 5-9)]. Median size of the primary tumour was 5.0 cm (range 2.0-7.0 cm). There was a significant increase in median ICG-R15 after stage 1 ALPPS (8.8% vs. 10.2%, p = 0.024) and increase in median sFLR after stage 1 ALPPS (34.4% vs. 53.0%, p = 0.012). Linear regression showed no significant correlation between sFLR increase and ICG-R15 (B = 0.26, 95% CI: -0.82, 1.34, p = 0.565). One patient had PHLF. Median time to local recurrence and metastatic recurrence was 14.4 months (range 6.9-21.9) and 7.5 months (range 6.9-17.3) respectively. OS and DFS were 50% and 40% respectively. Conclusions: No significant relationship was observed between ICG-R15 and sFLR. Volume increase may overestimate the functional increase following ALPPS. Larger studies are needed to validate our findings.

Indocyanine green dye and its application in gastrointestinal surgery: The future is bright green

“…A study by Schwarz et al [ 37 ] comprising 698 patients similarly showed that patients with impaired ICG clearance were twice as likely to have postoperative liver dysfunction. A recent retrospective study however highlighted that in patients treated with associating liver partition and portal vein ligation for staged hepatectomy, ICG-R15 overestimated the true liver function increase post-operatively[ 41 ]. These results remain to be validated, and are essential in tailoring treatment to prevent PHLF.…”

Correlation between the liver transection line localization and future liver remnant hypertrophy in associating liver partition and portal vein ligation for staged hepatectomy

“…Consequently, the function of the hypertrophied FLR was questioned (27). Studies using hepatobiliary scintigraphy (41), LIMAx test (42) and indocyanine green retention test (43) resulted in the same conclusion: the increase in FLR volume is not followed by a proportional increase in liver function. Thus, it is advocated by some authors to consider using these tests to evaluate FLR function before proceeding with the second stage of ALPPS.…”

Liver resection, and technical advances to mitigate post-hepatectomy liver failure

“…While these modalities are attractive, they also do not eliminate PHLF risk. For example, a local audit of 10 ALPPS patients revealed that volumetric increase does not correspond to liver function enhancement and one patient developed PHLF ( 13 ).…”