Parenchyma Sparing ALPPS - Ultrasound Guided Partition Through Segment 4 to Maximize Resectability (with video)

Botea, Florin; Bârcu, Alexandru; Croitoru, Adina; Tomescu, Dana; Lupescu, Ioana Gabriela; Dumitru, Radu; Herlea, Vlad; Verdea, Cosmin; Becker, Thomas; Popescu, Irinel; Linecker, Michael

doi:10.21614/chirurgia.2652.online.ahead.of.print.nov30

Cited by 2 publications

(6 citation statements)

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“…This first step of ALPPS is defined as enhanced because it is not a liver partition with a single transection line as for classical ALPPS [6] but it is a mesohepatectomy with two transection lines leaving deportalized liver well perfused without any parenchymal debris and first-order GPs are completely exposed and skeletonized. Enhanced ALLPS is defined parenchyma sparing (PS) when S4 is preserved in FLR [20] or in deportalized liver and best outflow is assured using communicating veins or vascular reconstructions if necessary. In the second stage the deportalized liver is resected.…”

Section: Ps E-alpps (Parenchyma-sparing Enhanced Alpps)mentioning

confidence: 99%

Vessel-Guided Mesohepatectomy for Liver Partition and Staged Major Parenchyma-Sparing Hepatectomies with Super-Selective Portal Vein Embolization or Enhanced ALPPS to Achieve R0 Resection for Colorectal Liver Metastases at the Hepatocaval Confluence

Urbani,

Roffi,

Moretto

et al. 2023

Cancers

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Background. R0 minor parenchyma-sparing hepatectomy (PSH) is feasible for colorectal liver metastases (CRLM) in contact with hepatic veins (HV) at hepatocaval confluence since HV can be reconstructed, but in the case of contact with the first-order glissonean pedicle (GP), major hepatectomy is mandatory. To pursue an R0 parenchyma-sparing policy, we proposed vessel-guided mesohepatectomy for liver partition (MLP) and eventually combination with liver augmentation techniques for staged major PSH. Methods. We analyzed 15 consecutive vessel-guided MLPs for CRLM at the hepatocaval confluence. Patients had a median of 11 (range: 0–67) lesions with a median diameter of 3.5 cm (range: 0.0–8.0), bilateral in 73% of cases. Results. Grade IIIb or more complications occurred in 13%, median hospital stay was 14 (range: 6–62) days, 90-day mortality was 0%. After a median follow-up of 17.5 months, 1-year OS and RFS were 92% and 62%. In nine (64%) patients, MLP was combined with portal vein embolization (PVE) or ALPPS to perform staged R0 major PSH. Future liver remnant (FLR) volume increased from a median of 15% (range: 7–20%) up to 41% (range: 37–69%). Super-selective PVE was performed in three (33%) patients and enhanced ALPPS (e-ALPPS) in six (66%). In two e-ALPPS an intermediate stage of deportalized liver PSH was necessary to achieve adequate FLR volume. Conclusions. Vessel-guided MLP may transform the liver in a paired organ. In selected cases of multiple bilobar CRLM, to guarantee oncological radicality (R0), major PSH is feasible combining advanced surgical parenchyma sparing with liver augmentation techniques when FLR volume is insufficient.

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Section: Ps E-alpps (Parenchyma-sparing Enhanced Alpps)mentioning

confidence: 99%

Vessel-Guided Mesohepatectomy for Liver Partition and Staged Major Parenchyma-Sparing Hepatectomies with Super-Selective Portal Vein Embolization or Enhanced ALPPS to Achieve R0 Resection for Colorectal Liver Metastases at the Hepatocaval Confluence

Urbani,

Roffi,

Moretto

et al. 2023

Cancers

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“…To further increase resectability while reducing morbidity, we proposed a new technical variant of ALPPS—parenchyma-sparing ALPPS (psALPPS)—that involves shifting the transection plane through segment 4 using IOUS guidance, preserving part of this segment along with the left lateral section [ 66 ]. Besides avoiding S4 necrosis, that is a source of complication when performing conventional ALPPS, a significant advantage of psALPPS lies in preventing major bile leaks at the transection surface by avoiding complete exclusion of S4 from the biliary system (as in conventional ALPPS).…”

Section: Regenerative Liver Surgerymentioning

confidence: 99%

“…Moreover, when compared to standard ALPPS, partitioning through segment 4, away from the umbilical portion of the left portal pedicle, protects against potential injuries of the vascular and biliary structures for segments 2 and 3. This new technical variant also embeds some of the main modifications already proposed, such as partial ALPPS, avoiding the transection beyond the middle HV, and delayed ALPSS [ 66 ]. It also adapts the concept of avoiding hilar dissection by adopting a minimal hilar dissection (right side approach only) [ 66 ].…”

Section: Regenerative Liver Surgerymentioning

confidence: 99%

“…This new technical variant also embeds some of the main modifications already proposed, such as partial ALPPS, avoiding the transection beyond the middle HV, and delayed ALPSS [ 66 ]. It also adapts the concept of avoiding hilar dissection by adopting a minimal hilar dissection (right side approach only) [ 66 ]. Using an extra-Glissonean approach to complete the hepatectomy during the second step further increases safety by avoiding re-dissection of the liver hilum.…”

Section: Regenerative Liver Surgerymentioning

confidence: 99%

“…PsALPPS combines both concepts of complex liver surgery, RS and PSS, which synergistically achieve resectability, which would otherwise not be possible with either approach [ 66 ].…”

Section: Parenchyma-sparing Vs Regenerative Liver Surgerymentioning

confidence: 99%

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Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go?

et al. 2022

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Liver resection for malignant tumors should respect oncological margins while ensuring safety and improving the quality of life, therefore tumor staging, underlying liver disease and performance status should all be attentively assessed in the decision process. The concept of parenchyma-sparing liver surgery is nowadays used as an alternative to major hepatectomies to address deeply located lesions with intricate topography by means of complex multiplanar parenchyma-sparing liver resections, preferably under the guidance of intraoperative ultrasound. Regenerative liver surgery evolved as a liver growth induction method to increase resectability by stimulating the hypertrophy of the parenchyma intended to remain after resection (referred to as future liver remnant), achievable by portal vein embolization and liver venous deprivation as interventional approaches, and portal vein ligation and associating liver partition and portal vein ligation for staged hepatectomy as surgical techniques. Interestingly, although both strategies have the same conceptual origin, they eventually became caught in the never-ending parenchyma-sparing liver surgery vs. regenerative liver surgery debate. However, these strategies are both valid and must both be mastered and used to increase resectability. In our opinion, we consider parenchyma-sparing liver surgery along with techniques of complex liver resection and intraoperative ultrasound guidance the preferred strategy to treat liver tumors. In addition, liver volume-manipulating regenerative surgery should be employed when resectability needs to be extended beyond the possibilities of parenchyma-sparing liver surgery.

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Parenchyma Sparing ALPPS - Ultrasound Guided Partition Through Segment 4 to Maximize Resectability (with video)

Cited by 2 publications

References 0 publications

Vessel-Guided Mesohepatectomy for Liver Partition and Staged Major Parenchyma-Sparing Hepatectomies with Super-Selective Portal Vein Embolization or Enhanced ALPPS to Achieve R0 Resection for Colorectal Liver Metastases at the Hepatocaval Confluence

Vessel-Guided Mesohepatectomy for Liver Partition and Staged Major Parenchyma-Sparing Hepatectomies with Super-Selective Portal Vein Embolization or Enhanced ALPPS to Achieve R0 Resection for Colorectal Liver Metastases at the Hepatocaval Confluence

Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go?

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