Speciális májműtét (Associating Liver Partition and Portal vein ligation for Staged hepatectomy, ALPPS) morbiditásának csökkentése átértékelt betegkiválasztási elvek és műtéttechnikai módosítás révén

Abstract

Introduction: Resecability of liver tumors is exclusively depending on the future liver remnant (FLR). The remnant can be hypertrophised using portal vein occlusion techniques. The latest hypertrophising method is Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), which provides the most significant induced hypertrophy in the shortest time. Morbidity and mortality of this procedure were initially unacceptably high. Aim: Reducing complications by better patient selection and modified surgical technique. Method: The First Department of Surgery, Semmelweis University, Budapest, prefers the ‘no touch’ technique, instead of ‘complete mobilization’. For optimizing patient selection, an international registry (including our patients’ data) was established. In addition to the surgical, we collected demographic, disease, liver function, histology, morbidity (Clavien–Dindo) and mortality parameters. Volume and function measurements were performed by using CT-volumetry and 99mtechnecium-mebrofenin SPECT/CT. Data were analyzed by multivariate analysis (significance: p<0.05). Results: We performed 20 ALPPS procedures from 2012 to 2018. The relative volume increment and resectability in our department and among the 320 registry patients were 96% vs. 86% and 95% vs. 98%. Using ‘no touch’ technique, the Clavien–Dindo III–IV morbidity and mortality rates were significantly lower (22%–0%) than with ‘complete mobilization’ (63%–36%) (p<0.05). Based on the multivariate analysis of the registry patients, age over 60 years, liver macrosteatosis, non-colorectal liver tumor, >300 minutes operation time, >2 units of red blood cell transfusion, or insufficient FLR function before stage 2 were identified as independent factors influencing mortality (p<0.05). Conclusion: Mortality and morbidity of ALPPS can be reduced by proper patient selection and ‘no touch’ surgical technique. Orv Hetil. 2019; 160(32): 1260–1269.

Ipsilateral access portal venous embolization (PVE) for preoperative hypertrophy exhibits low complication rates in Clavien-Dindo and CIRSE scales

“…Wajswol et al (Wajswol et al 2018) reported that 76% of PVE candidates underwent surgical resection. A 20% drop-out rate after first stage resection from disease progression was reported in another two-stage hepatectomy series (Narita et al 2011;Hahn et al 2019). In central bile duct tumors, a 25% rate of nonresectability has been reported in a larger series by Ebata et al (Ebata et al 2012).…”

“…Another group reported severe morbidity (Clavien- Dindo ≥3a) to occur in 50% (3/6) of the rescue ALPPS, 71% (10/14) of the ALPPS, and 38% (13/34) of the TSH/PVE patients ( p = 0.300) (Narita et al 2011 ). Consequently, for example Hahn et al, (Hahn et al 2019 ) modified their surgical strategy and reported a Clavien-Dindo III-IV morbidity of 22% and mortality of 0%.…”

Májsebészet a Semmelweis Egyetem I. sz. Sebészeti Klinikáján

“…10 A rendkívül magas reszekciós arány ellenére a szövődmények lehetősége miatt az eljárás csak szoros feltételek mellett történő betegszelekció után végezhető. Az eljárás kidolgozásában, a szövődmény arányának csökkentésében, a műtéti technika módosításában klinikánk világviszonylatban is vezető szerepet játszik [11][12][13] Ennek standard eljárása a 70-es évek elejére alakult ki: 2 × 30 perc, közte 2-3 perces szünet "fl ush" perfúzióval. Évente 20-30 jelentősebb májreszekció történt.…”