Ligadura da veia porta associada à bipartição do fígado para hepatectomia em dois estágios (ALPPS): experiência brasileira

Abstract

-Background -Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. To induce rapid and significant hepatic hypertrophy, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients which tumor is previously considered unresectable. Aim -To present the Brazilian experience with ALPPS approach. Method -Were analyzed 39 patients who underwent hepatic resection using ALPPS in nine hospitals. The procedure was performed in two steps. The first operation was portal vein ligation and in situ splitting. In the second operation the right hepatic artery, right bile duct and the right hepatic vein were isolated and ligated. The extended right lobe was removed. There were 22 male (56.4%) and 17 female (43.6%). At the time of the first operation, the median age was 57.3 years (range: 20-83 years). Results -The most common indication was liver metastasis in 32 patients (82.0%), followed by cholangiocarcinoma in three (7.7%). Two patients died (5.2%) during this period and did not undergo the second operation. The mean interval between the first and the second operation was 14.1 days (range: 5-30 days). The volume of the left lateral segment of the liver increased 83% (range 47-211.9%). Significant morbidity after ALPPS was seen in 23 patients (59.0%). The mortality rate was 12.8% (five patients). Conclusion -The ALPPS approach can enable resection in patients with lesions previously considered unresectable. It induces rapid liver hypertrophy avoiding liver failure in most patients. However still has high morbidity and mortality.RESUMO -Racional -Insuficiência hepática pós-operatória devido à remanescente hepático pequeno tem sido complicação temida em pacientes que são submetidos à ressecção hepática extensa. A ligadura da veia porta associada à bipartição do fígado para hepatectomia em dois estágios (ALPPS) foi desenvolvida recentemente com a finalidade de induzir rápida e significante regeneração do fígado para pacientes em que o tumor é previamente considerado irressecável. Objetivo -Apresentar a experiência brasileira com o ALPPS. Método -Foram analisados 39 pacientes submetidos ao procedimento ALPPS em nove hospitais. Ele foi realizado em duas etapas. A primeira operação consistiu em ligadura do ramo direito da veia porta e bipartição hepática. Na segunda, os ramos direito da artéria hepática, via biliar e veia hepática foram ligados e o lobo hepático direito estendido foi removido.

Applying negative pressure wound therapy in associating liver partition and portal vein ligation for staged hepatectomy: A case report

“…Schnitzbauer et al (5) indicated that a two-staged hepatectomy was performed for the first time in a patient with hilar cholangiocarcinoma in 2007 and that associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), a surgical approach for liver cancer with excessive tissue resection, was first described in 2012. However, ALPPS surgery has several limitations, including a large wound surface, incomplete drainage and high mortality rates (5,6). Acute liver and renal failure and infectious complications have been identified as predominant causes for mortality (6).…”

Associating liver partition and portal vein ligation for staged hepatectomy: A surgical technique for liver resections

“…The procedure is consisted of two-staged hepatectomy by which rapid significant hypertrophy of the remnant is induced by transecting the parenchyma while there is not enough time for the development of collateral formation. [10111213141516] The technique is relied on portal vein ligation and in situ splitting through parenchyma so that the two parts are just connected through hilar structures in the first step. Partitioning will be completed after an interval of 7 days if FLR hypertrophy is satisfactory.…”

“…Partitioning will be completed after an interval of 7 days if FLR hypertrophy is satisfactory. [1316] There are promising results on remnant growth rate by ALPPS procedure in literature. [1718] But the reason that the technique is not approved yet is lack of being evaluated technically in early development phase till now.…”

Abdominal cross-sectional imaging of the associating liver partition and portal vein ligation for staged hepatectomy procedure

“…It should be kept in mind that ALPPS is an “extrema ratio” procedure to be proposed after careful, multidisciplinary patient selection[6,23,24]. Morbidity and mortality amount up to 14% and 6.6% in experienced centers applying strict selection criteria[10,25-27].…”

“…FLR volume should be calculated by excluding major vessels and FLLs, in order to obtain a reasonable estimate of final viable liver tissue supporting liver function. FLR should be no lower than 25%-30% of preoperative liver volume in patients with normal liver function, and no lower than 40% in patients with underlying chronic liver disease or liver dysfunction (including the effects of chemotherapy)[7,23,50-52]. Many dedicated liver volumetry software are currently available, most times implemented in the picture archive and communication systems used for routine image analysis.…”