Diagnostics and surgical treatment of liver echinococcosis in Latvia

The results of treatment of 44 patients (during the period 1996 - 2010) with liver echinococcosis (LE) were analysed. Echinococcosis hydatid (EH) cyst was found in 15 patients, alveolar echinococcosis (AE)--in 29 patients, 11.3% of cases were asymptomatical, different clinical symptoms were found in 36.4% of patients and 52.3% of patients were admited due to severe complications. Surgical treatment was performed in 41 patients. Among 15 patients with hydatid liver cyst 3--underwent liver resection, 8--pericystechinococcectomy, 4--guided percutaneous treatment--PAIR. No complications or recurrences were noted. Radical operations were performed in 12 patients with AE (41.3%), 11 of them had asymptomatical or noncomplicated disease. Recurrence appeared in one patient (8.3%). Nonradical or palliative operations due to AE complications were performed in 15 patients (51.7%). Complication at the postoperative periods occurred in 17% of patients with AE and lethality rate came to 3.4%. The diagnosis made at the early asymptomatic state and the following selection of combination of surgical approach and medicamental treatment (albendazol) can improve the results of treatment of patients with liver echinococcosis.     

剩余肝体积不足的晚期肝泡型包虫外科治疗进展

剩余肝体积(RLV)不足是肝切除术后肝功能衰竭和患者死亡的主要原因.肝泡型包虫(HAE)常侵及肝内外重要血管,致使功能肝段的保留极为困难,根治性切除率低.尽管离体肝切除联合自体肝移植术(ERAT)极大拓宽了晚期HAE手术指征,但RLV不足仍是限制HAE根治性切除的主要因素.近年来,包括分期肝切除、肝静脉支架置入序贯ER...     

Associating liver partition and portal vein ligation for staged hepatectomy:From technical evolution to oncological benefit

Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) is a novel approach in liver surgery that allows for extensive resection of liver parenchyma by inducing a rapid hypertrophy of the future remnant liver. However,recent reports indicate that not all patients eligible for ALPPS will benefit from this procedure. Therefore,careful patient selection will be necessary to fully exploit possible benefits of ALPPS. Here,we provide a comprehensive overview of the technical evolution of ALPPS with a special emphasis on safety and oncologic efficacy. Furthermore,we review the contemporary literature regarding indication and benefits,but also limitations of ALPPS.     

Initial clinical results of orthotopic liver transplantation for hepatic alveolar echinococcosis.

We analyzed the features of 7 patients who underwent orthotopic liver transplantation (OLT) from April 2001 to April 2006 for incurable hepatic alveolar echinococcosis (AE) in view of the technical features of the OLT, incidence, and type of complications, as well as patient survival. All 7 patients had biliary diseases that resulted from parasitic involvement of the hilum or a large parasitic lesion that invaded the lobes of the liver due to parasitic involvement of the hepatic veins, which are all typical syndromes of hepatic AE. Five patients had previously undergone surgery for hepatic AE and were at the end stage of liver functional disorder. Four patients' operations were performed under venovenous bypass. The mean duration of surgery was 9.1 hours. After transplantation, one patient experienced biliary leakage but was successfully treated with reoperation. One patient died 21 days later of septicemia caused by pneumonia and multiple organ failure, and another patient died 3 months after OLT from heart failure. The other 5 patients are alive and in good condition after transplantation. Although the transplantation procedure was more difficult than usual in these patients, most achieved prolonged survival and a good quality of life. This study suggests that OLT is feasible for incurable AE of the liver and that this procedure ensures a good clinical outcome.     

全腹腔镜联合肝脏离断和门静脉结扎的二步肝切除术治疗肝硬化肝癌

联合肝脏离断和门静脉结扎的二步肝切除术（ALPPS）被誉为肝胆外科领域革命性突破,通过第1步手术刺激剩余肝脏再生,第2步手术行根治性切除,为不能行手术切除的肝癌患者提供了在1次住院期间获得根治性切除的机会.2014年4月第三军医大学西南医院收治1例合并肝硬化的右肝原发性肝癌患者.术前评估行右半肝切除术后剩余肝脏体积占标准肝脏体积的26.9％.采用全腹腔镜ALPPS方案：第1步手术行腹腔镜下右侧Glisson蒂悬吊,门静脉右支结扎,肝后间隙放置绕肝带,正中裂原位肝实质完全离断.第1步手术后13 d再次计算剩余肝脏体积占标准肝脏体积的40.6％.于第1步手术后14 d行第2步手术：腹腔镜下采用直线切割闭合器离断右侧Glisson蒂及肝右静脉,处理右半肝周围韧带,完整切除右半肝及肿瘤,于耻骨上横切口取出标本.切缘距离肿瘤1.5 cm.患者第1步手术后无并发症发生,第2步手术后并发右侧胸腔积液行穿刺引流,于第2步手术后第9天痊愈出院.术后1个月门诊复查肝功能正常,无肝脏占位性病变和胸腔积液.全腹腔镜ALPPS治疗肝硬化肝癌安全可行,手术效果良好.     

ALPPS可能是治疗预留肝体积不足的伴门静脉癌栓肝细胞癌的有效方法

目的 提供联合肝脏分隔和门静脉结扎的二步肝切除术(ALPPS)应用于门静脉癌栓病例中的经验,初步探讨其在门静脉癌栓病例治疗中的价值和进一步发展方向.方法 对解放军总医院肝胆外科2015年7月-2016年12月收治的3例应用于门静脉癌栓的ALPPS手术进行回顾性分析,采集患者基本信息、术前门静脉癌栓分型、术前肝功能Child-Pugh分级、ICG试验结果、预留肝体积、预留肝体积增长率、两期手术的手术时间、出血量、术后并发症情况、术后生存情况等关键临床数据,并结合文献进行讨论分析.结果 3例患者均完成ALPPS手术.根据门静脉癌栓的程树群分型,Ⅱ型1例,Ⅲ型2例.一期术前肝功能均为Child-Pugh A级,ICG R15平均为7.3％(4.2％～11.0％),平均预留肝体积387 ml(333 ～484 ml).两期手术平均间隔时间为24.7 d(9～50 d),平均预留肝体积的增长率为50.3％ (24.4％ ～ 82.3％).术后Clavien-DindoⅢ级以上的并发症1例,未出现死亡患者.截至2017年2月,2例患者因肿瘤复发行肝动脉化疗栓塞治疗,效果良好.所有患者均生存情况良好.解剖二期手术标本,均见癌栓坏死.结论 对于门静脉癌栓Ⅱ型和Ⅲ型的低预留肝体积患者,ALPPS是一种能够有效控制癌栓、提高根治性切除率的有价值的手术方式,结合肝动脉化疗栓塞等治疗方式有望进一步提高治疗效果.     

Die chirurgische Therapie der alveolären Echinokokkose und deren Langzeitergebnisse

INTRODUCTION: The incidence of alveolar echinococcosis (AE) is low, and studies and progress reports with regard to surgical procedures are rare. METHODS: Retrospective analysis of surgical therapy of AE and its long-term results between 1983 and 2000 by evaluating medical records and questionnaires. SETTING: German university hospital within the endemic area. RESULTS: Twenty-five surgical procedures were performed in 19 patients with AE (12x partial resection of the liver, 3 of them with additional extrahepatic resection; 3x just extrahepatic resection, 4x bilidigestive anastomosis, 5x exploratory laparotomy, 1x bypass procedure). Fifteen patients were operated on the first time with that diagnosis, four due to a relapse. Seven surgical procedures were estimated to be curative, whereas 18 were palliative, because the parasitic mass could not be resected in toto. One patient died from persistent systemic sepsis as a consequence of microbial superinvasion of a splenic parasitic mass. Morbidity was 28%. All patients had additional medical treatment and periodic follow-up. Three of seven patients estimated for curative surgery developed a relapse. One of the patients discharged following palliative surgery died 13 years after diagnosis with liver insufficiency. Advances in conservative and interventional treatments have greatly improved the prognosis of the disease. CONCLUSION: Curative surgery for AE is feasible only in a minority of patients, because frequently the disease has already spread widely when diagnosed. The minimum distance between the lesion and the cut surface should be 2 cm. Taking the advances in conservative treatment into consideration, the benefit of palliative surgery is uncertain and today there is no evidence for prolonged survival by palliative surgical procedures. Palliative surgery should therefore be reserved for cases with complications that could not be managed by conservative and interventional treatment.     

全腹腔镜ALPPS治疗肝脏恶性肿瘤(附三例报告及文献复习)

目的探讨全腹腔镜联合肝脏离断和门静脉结扎的二步肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS)治疗肝脏恶性肿瘤的治疗选择。方法回顾性分析2019年中国科学技术大学附属第一医院肝脏外科行全腹腔镜ALPPS治疗的1例直肠癌术后肝脏多发转移和2例巨块型肝癌的临床资料,分析围手术期检查指标和术后随访结果以评价该术式的临床应用价值。结果第一步手术均在腹腔镜下行门静脉右支结扎和原位肝实质离断+胆囊切除术,第一次和第二次术前三维可视化结果显示,3例病例术前两次预估剩余肝脏体积分别为221 ml和364 ml,320 ml和532 ml以及332 ml和422 ml,预留肝脏体积较前增加了65%、66%和27%,在剩余肝脏体积比达到安全标准后第二步手术行解剖性右三叶肝切除术,术后对症治疗肝功能逐渐恢复,围手术期无死亡及其他严重并发症,随访至今未见肿瘤复发、无远处转移。结论全腹腔镜下可以安全地、有效地开展ALPPS,预留肝脏短期内能代偿增生。腹腔镜ALPPS为复杂的肝脏恶性肿瘤创造了手术切除的可能性。     

Associating liver partition and portal vein ligation for staged hepatectomy in the treatment of colorectal cancer liver metastases

Colorectal cancer (CRC) is a common malignancy of the digestive system. Colorectal liver cancer metastasis (CRLM) occurs in approximately 50% of the patients and is the main cause of CRC mortality. Surgical resection is currently the most effective treatment for CRLM. However, given that the remnant liver volume after resection should be adequate, only a few patients are suitable for radical resection. Since Dr. Hans Schlitt first performed the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for CRLM in 2012, ALPPS has received considerable attention and has continually evolved in recent years. This review explains the technical origin of the ALPPS procedure for CRLM and evaluates its efficacy, pointing to its favorable postoperative outcomes. We also discuss the patient screening strategies and optimization of ALPPS to ensure long-term survival of patients with CRLM in whom surgery cannot be performed. Finally, further directions in both basic and clinical research regarding ALPPS have been proposed. Although ALPPS surgery is a difficult and high-risk technique, it is still worth exploration by experienced surgeons.     

Hepatic infestation of <Emphasis Type="Italic">Echinococcus multilocularis</Emphasis> with extension to regional lymph nodes

Objective  The objective of this paper is to prove lymph node infestation by Echinococcus multilocularis and provide evidence for systematic lymph node dissection in curative resections for alveolar echinococcosis (AE). Background  Human AE is a life threatening parasitic condition, usually caused by an intrahepatic infiltrative and destructive growth of the larvae E. multilocularis. WHO guidelines provide radical hepatic resection for curative treatment. However, the current norms do not consider dissection of regional lymph nodes. No report to date has visualized concurrent lymph node infestation. Methods  Radical excision of infested liver including regional lymph nodes with subsequent histological examination was carried out in a patient suffering from AE. The literature was reviewed and a revised state-of-the-art treatment of AE deduced. Results  Upon inspection the liver displayed macroscopic features of AE, in contrast to the regional lymph nodes which appeared unsuspicious. Further histological analysis confirmed regional lymph node infestation of E. multilocularis. Conclusions  This is the first publication on histological evidence of E. multilocularis in regional hepatic lymph nodes, and thus, demonstrating dissemination from the liver. Since AE can spread through lymphatic drainage, even without causing macroscopic conspicuity, resection should not be resumed to the liver tissue only, but rather to consider the routine removal of regional lymph nodes as well. Omission of lymph node dissection can leave behind parasitic tissue and surgical procedures erroneously judged as curative.     

ALPPS Offers a Better Chance of Complete Resection in Patients with Primarily Unresectable Liver Tumors Compared with Conventional-Staged Hepatectomies: Results of a Multicenter Analysis

Background

Portal vein occlusion to increase the size of the future liver remnant (FLR) is well established, using portal vein ligation (PVL) or embolization (PVE) followed by resection 4–8 weeks later. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) combines PVL and complete parenchymal transection, followed by hepatectomy within 1–2 weeks. ALPPS has been recently introduced but remains controversial. We compare the ability of ALPPS versus PVE or PVL for complete tumor resection.

Methods

A retrospective review of all patients undergoing ALPPS or conventional staged hepatectomies using PVL or PVE at four high-volume HPB centres between 2003 and 2012 was performed. Patients with primary liver tumors and liver metastases were included. Primary endpoint was complete tumor resection. Secondary endpoints include 90-day mortality, complications, FLR increase, time to resection, and tumor recurrence.

Results

Forty-eight patients with ALPPS were compared with 83 patients with conventional-staged hepatectomies. Eighty-three percent (40/48 patients) of ALPPS patients achieved complete resection compared with 66 % (55/83 patients) in PVE/PVL (odds ratio 3.34, p = 0.027). Ninety-day mortality in ALPPS and PVE/PVL was 15 and 6 %, respectively (p = 0.2). Extrapolated growth rate was 11 times higher in ALPPS (34.8 cc/day; interquartile range (IQR) 26–49) compared with PVE/PVL (3 cc/day; IQR2-6; p = 0.001). Tumor recurrence at 1 year was 54 versus 52 % for ALPPS and PVE/PVL, respectively (p = 0.7).

Conclusions

This study provides evidence that ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors at the cost of a high mortality. The technique is promising but should currently not be used outside of studies and registries.     

Alveolar echinococcosis of the liver. Mass ultrasound screening in the Haut Cantal area

Mass systematic screening for alveolar echinococcosis (AE) of the liver in the Haut Cantal endemic area.     

联合肝脏离断和门静脉结扎的二步肝切除术研究进展

联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)作为一种新的外科手术方法,给因传统手术后剩余肝脏体积不足而不能接受大范围肝切除术的患者带来了希望。该方法一经提出便得到肝外科学家们的青睐,并在应用中不断地提出新的改进方法。早期的研究结果表明ALPPS的手术病死率和并发症发生率较高,随着技术的发展,已有零病死率报道。但是ALPPS后的远期治疗效果尚无明确报道。笔者复习相关文献就该技术的应用进行综述。     

肝泡型包虫病根治性切除163例回顾性分析

目的:探讨肝泡型包虫病根治性切除的治疗效果。方法:回顾性分析2013年1月—至2015年6月163例行根治性切除肝泡型包虫病患者的临床资料。结果:根治性手术平均时间(3.1±1.2)h,术中出血量(763±498)m L。术后携带腹腔引流管中位时间6 d,11例携带T管,术后1个月拔除。术后平均肛门排气时间(2.1±0.8)d、经口进食时间(2.7±1.1)d、住院时间(7.9±3.4)d。8例出现术后并发症,其中5例术后胆瘘,1例术区感染,2例术后腹水。术后电话或门诊随访1~6个月无死亡及包虫复发情况。结论:根治性切除是当前肝泡型包虫病患者的首选治疗方案。术前充分评估手术可行性,术中充分掌握肝脏血流控制、肝脏外科解剖、门静脉重建、胆管重建等技术,通过根治性手术切除可明显改善泡型包虫病患者的生存质量,延长患者的生存时间。     

联合肝脏离断和门静脉结扎两阶段肝切除术在治疗中晚期肝癌中的应用

联合肝脏离断和门静脉结扎的两阶段肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS)是近几年提出的一种全新手术方式,因其能显著促进肝组织增生,明显缩短两次手术时间间隔,所以可用于剩余正常肝脏体积不足,不能接受大范围切除的中晚期肝癌病人。目前该术式仍存在风险和难点,有着较高的并发症发生率和病死率,短期效果尚可,但其所带来的长期存活获益尚无定论,故其发展一直伴随着诸多的争议。本文就ALPPS的相关应用进展等作一综述。     

Associating liver partition and portal vein ligation (ALPPS): A two staged procedure,in Bogotá Colombia. Case report and literature review

IntroductionFor liver tumors (primary or metastases), surgery combined with neoadjuvant, or adjuvant chemotherapy is the treatment of choice, offering long term survival time and disease-free time period (Alvarez et al., 2012) Associating liver partition and portal vein ligation, or ALPPS, it's a surgical technique that increases the future liver remnant in a short period of time, trying to avoid postoperative liver failure (PLF), and achieving R0 resections in liver malignant tumors (Alvarez et al., 2012).Presentation of the caseA 43 years old woman with colorectal liver metastases in both lobes. Colorectal surgical procedure was performed 1 year previous the liver intervention, followed by adjuvant chemotherapy. Decision of a tri-segmental hepatectomy was made to resolve the metastases. Into the surgical procedure, we evaluated the liver parenchyma, and the future liver remnant tissue was insufficient, for that reason we decided to perform ALPPS procedure.DiscussionColorectal liver metastases (CLRM) are considered the most common indication for ALPPS procedure according to the international registry. Compared with the portal vein ligation, resection rate varies from 50 to 80%, and the non-resectability disease was explained by tumor progression. Postoperative mortality rate was 5.1% in young patients (<60 years old), and 8% in general for CRLM. Oncologic outcomes represent an increased disease-free survival period and overall survival time compared with non-surgical approach.ConclusionThe ALPPS procedure it's an interesting approach to patients with not enough liver remnant tissue, with good oncologic results in terms of disease-free survival time, and overall survival. Appropriate selection of the patient, careful postoperative management, and a multidisciplinary approach are related with good postoperative outcomes.     

Hepatic resection for alveolar echinococcosis

The authors report their experience with 20 patients who underwent liver resection for alveolar echinococcosis of the liver from June 1982 to March 1991. Resection was radical in 9 patients and non radical in 11 patients. The 9 patients treated by radical resection are alive. 8 patients are symptom-free and disease-free when one patient with a parasitic recurrence underwent another radical resection. Among the 11 patients treated by non radical resection, 4 of them died during the follow-up period, the cause of the death being related to the disease in 3 cases and non related in one case. When feasible, radical liver resection is the best form of therapy. When massive parasitic invasion precludes radical hepatectomy, non radical resection associated if necessary with percutaneous procedures should be considered before embarking on orthotopic liver transplantation.     

First Ever Robotic Stage One ALPPS Procedure in India: for Colorectal Liver Metastases

Twenty five percent of total liver volume (TLV) is considered as the ideal functional liver remnant (FLR) in major liver resections. In patients with macro-vesicular steatosis, early cirrhosis, and post-neoadjuvant chemotherapy (NACT), hepatocellular injury is common. In such instances, up to 40% of FLR may be required. So in cases of marginal FLR, pre-operative portal vein (PV) embolization or two-stage hepatectomy with PV occlusion is used. Both of which take up to 14 weeks between stages and 30% of patients fail to reach the second resection either due to inadequate FLR growth or disease progression. Associated liver partition and portal vein ligation (ALPPS) procedure has become the gold standard for those cases. A 57-year-old male presented with rectosigmoid growth + multiple right liver and segment 4B metastases. Post-NACT MRI showed interval progression of lesions. Preoperative CT (computed tomography) volumetric scan showed a FLR/TLV (future liver remnant/total liver volume) of 22%. Since patient received 10 cycles of NACT, ALPPS procedure was planned ahead of direct liver resection. Robotic ALPPS stage 1 sparing left lateral segment and 4A + anterior resection was done. We transected the parenchyma between the FLR and the diseased part of the liver with concomitant right portal vein ligation done robotically. CT abdomen done on POD7 showed hypertrophied left lateral segment. Second stage was performed on the eighth post-operative day with FLR/TLV increasing to 37%. Robotic ALPPS procedure for stage one is a safe and feasible technique in experienced centers with advanced robotic skills.     

联合肝脏分隔和门静脉结扎二步肝切除术治疗传统不可切除肝癌之进展

近年来,肝癌综合治疗进展显著,但手术切除仍为肝癌病人获得长期生存的主要治疗方式。随着肝脏外科的快速发展,肝脏解剖学的复杂性和手术操作已不再是肝脏手术的主要障碍,肝切除术后剩余肝脏体积不足成为肝脏手术的主要限制因素。临床上多数肝癌病人因此无法行一期根治性切除术,只能接受非手术治疗,长期预后较差。联合肝脏分隔和门静脉结扎二...     

ALPPS促进剩余肝脏快速增生机制及相关因素研究进展

联合肝脏离断和门静脉结扎的二步肝切除术(ALPSS)是近年来发展起来的一种新型二步肝切除术。ALPPS最大特点是能够在短期内促进剩余肝脏体积(FLR)快速急剧增生,相比传统二步肝切除术,具有更高二期手术完成率和R_0切除率,让因FLR不足而无法行根治性切除的肝癌患者有了治愈的希望。笔者对ALPPS促进FLR快速增生机制及相关因素研究进展进行综述。