Ligadura da veia porta associada à transecção para hepatectomia em dois estágios (ALPPS): uma nova abordagem nas ressecções hepáticas

Abstract

-Background -Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a new approach for patient which tumor is previously considered unresectable.Aim -To present ALPPS as an innovative surgical technique of two-staged hepatectomy for the treatment of patients with marginally resectable or initially nonresectable primary and metastatic liver tumors. Technique -The procedure is performed in two steps. The first consists on ligation of the right portal vein branch. Subsequently, total or nearly total parenchyma dissection along the falciform ligament is performed, including the middle hepatic vein. A plastic bag is used to cover the right extended lobe, and the abdomen is drained and closed. The second one is performed after a computer tomography, six to 12 days interval. After laparotomy, the plastic bag is removed. The right artery, right bile duct and the right hepatic vein are divided. The extended right lobe is removed. Drain is placed at the resection surface, and the abdomen is closed. Conclusion -The associating of liver partition and portal vein ligation can enable curative resection of liver metastasis in patients with lesions previously considered unresectable. ABCDDV/886RESUMO -Racional -Insuficiência hepática pós-operatória devido a remanescente hepático pequeno tem sido complicação temida em pacientes que são submetidos à ressecção hepática extensa. A associação da transecção hepática e ligadura da veia porta para hepatectomia estagiada (ALPPS) é uma nova abordagem para pacientes em que o tumor é previamente considerado irressecável. Objetivo -Apresentar a técnica ALPPS como procedimento novo de hepatectomia em dois estágios com ligadura da veia porta e transecção hepática mantendo o fígado in situ para o tratamento de pacientes com tumores primários ou metastáticos marginalmente ressecáveis. Técnica -O procedimento é realizado em dois tempos. O primeiro consiste na ligadura do ramo direito da veia porta. Em seguida é realizada a transecção total ou quase total do parênquima hepático acompanhando o ligamento falciforme, incluindo a veia hepática média. Um saco plástico é utilizado para recobrir o fígado que será retirado; o abdome é drenado e realizada a síntese da parede por planos. O segundo tempo é feito após seis a 12 dias de intervalo com realização de tomografia computadorizada de abdome. Na laparotomia o saco plástico é removido. Os ramos direito da artéria hepática, ducto hepático e veia hepática são ligados e o lobo hepático direito é removido. Um dreno é posicionado na superfície de ressecção e a síntese da parede abdominal é realizada. Conclusão -ALPPS permite ressecção curativa de lesões hepáticas em pacientes com doença considerada previamente irressecável.

ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review

“…In our experience, sufficient hypertrophy of FLR was obtained in 10.8 days: this time span is significantly lower than the average time required when using PVO (40 days), minimizing the risk of progression of the tumor between the two steps of the procedure [ 3 , 17 ].…”

Transection of the hepatic parenchyma associated or not with the contralateral portal vein branch ligature and its effect in liver regeneration

“…However, this resection is limited by the need to preserve a sufficient remnant volume of liver, since an excessive resection can lead to liver failure within a few days after the surgical procedure. 10 , 11 …”

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

“…Hepatectomy is subsequently performed to separate the FLR from DH completely (complete ALPPS) or partially (partial ALPPS)[32,38]. If affected by metastases, the FLR is cleaned up by wedge resections and/or intraoperative radiofrequency ablation[17,26]. At the end of the procedure, DH is left in situ, often after having enveloped it into a hermetic bag made of plastic or a biodegradable type-I acellular collagen membrane[39].…”

“…The key technical point in ALPPS is the preservation of hepatic artery blood flow to the diseased hemiliver (DH) at the time of first surgical stage. Preserved arterialization leads the DH to act as a vital auxiliary liver and assist the growth of FLR through metabolic and synthetic functions[16,17]. ALPPS achieves a high rate of tumor complete resection (83%)[18], given the successful rate of adequate FLR growth (78%-91%)[19].…”