对ALPPS手术实用性与安全性的系统回顾和Meta分析

目的 通过联合肝脏分隔和门静脉结扎的二步肝切除术(ALPPS)和传统二阶段手术(TSH)进行系统回顾和Meta分析,综合评价这两种手术的实用性和安全性.方法 运用计算机检索MEDLINE、EMBASE等数据库,查找2013-2016年关于ALPPS手术和TSH手术临床相关文献资料.运用Revmen 5.0软件进行统计学分析,计量资料采用均数差(MD)作为评价分析统计量;计数资料采用比值比(OR)作为评价分析统计量,各效应量均以95％可信区间(CI)表示.异质性检验采用x2检验(检验标准为P ＜0.05),无异质性采用固定效应模型,在异质性较高的情况下,则采用随机效应模型.结果 经过筛查,4项研究共312例手术符合纳入标准.将两组手术进行Meta分析,研究结果显示,ALPPS组FLR增长率明显高于TSH组(MD =24.78;95％ CI:0.63 ～48.94;P=0.04);且ALPPS组FLR增长时间较TSH组显著缩短(MD=-26.55;95％CI:-37.13～-15.97;P＜0.05);ALPPS组术后严重并发症(≥Ⅲb)的发病率要高于TSH组(OR=2.47;95％CI:1.14～5.36;P =0.02);而ALPPS组和TSH组术后病死率没有明显区别(OR=2.43;95％ CI:0.94～6.31;P =0.07).结论 ALPPS手术较TSH手术可以更好地在较短时间内使预留残肝体积增长到安全切除范围,且两组术后病死率无明显差别,但ALPPS较TSH术后严重并发症(≥Ⅲb)的发病率仍然很高.     

Transcatheter arterial embolization-salvaged ALPPS,a novel ALPPS procedure especially for patients with hepatocellular carcinoma and severe fibrosis/cirrhosis

BackgroundThe associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for hepatocellular carcinoma (HCC) with fibrosis/cirrhosis is often associated with limited growth of future liver remnant (FLR). We introduced a new procedure named transcatheter arterial embolization-salvaged ALPPS (TAE-salvaged ALPPS) which was shown to be especially suitable for HCC patients with cirrhosis or fibrosis who failed adequately to respond to conventional ALPPS. The short-term efficacy and safety for the TAE-salvaged ALPPS on patients with HCC and fibrosis/cirrhosis were studied.MethodsConsecutive HCC patients who underwent TAE-salvaged ALPPS in our hospital between November 2016 and June 2020 were retrospectively studied. The new ALPPS procedure included conventional ALPPS stage-1 using associating liver partition and portal vein ligation. When FLR failed to reach sufficient hypertrophy, TAE was carried out 2 weeks later followed by liver resection 3 weeks after ALPPS stage-1.ResultsNine of 10 patients had a single tumor (median diameter 14.0 cm, range, 5.2–17 cm). The remaining patient had multiple tumors (diameter of one tumor 14.0 cm, and two satellite foci 2.0 and 3.0 cm). R0 resection was achieved in all patients (100%) after a median of 21 days. Six patients had cirrhosis, 1 had METAVIR grade-3 fibrosis, and 3 had METAVIR grade-2 fibrosis. The median increase in FLR volume after TAE-salvaged ALPPS was 69.7% (34.4–143.9%). The absolute and relative kinetic growth rates (KGRs) were 9.9 (7.1–17.3) mL/day and 3.4% (1.9–7.2%)/day, respectively. The median absolute KGRs were 15.7, 2.6, and 19.5 mL/day in the first, second, and third postoperative weeks after ALPPS stage-1, respectively. The rapid increase in KGR on the third week was induced by TAE. The overall postoperative morbidity rates were 50,0% (5/10), 20.0% (2/10) and 70.0% (7/10) after ALPPS stage-1, TAE and ALPPS stage-2, respectively. The 90-day mortality rate was 10.0% (1/10). The median overall survival was 40 months.ConclusionsThe new TAE-salvaged ALPPS induced significant increases in FLR volumes within 3 weeks in patients with HCC and fibrosis/cirrhosis. The procedure is promising in treating patients with HCC and fibrosis/cirrhosis who fail to achieve sufficient FLR hypertrophy after conventional ALPPS stage-1.     

Neoadjuvant radiotherapy for resectable hepatocellular carcinoma with portal vein tumor thrombus: a systematic review

BackgroundThe prognosis of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is extremely poor. The clinical outcome of preoperative radiotherapy (RT) is still controversial. This study aimed to compare the clinical outcomes of combined neoadjuvant RT and hepatectomy with hepatectomy alone for HCC with PVTT.MethodsComprehensive database searches were performed in PubMed, the Cochrane Library, EMBASE, and the Web of Science to retrieve studies published from the database creation to July 1, 2020. Only comparative studies that measured survival between neoadjuvant RT followed by hepatectomy and hepatectomy alone were included. The characteristics of the included studies and patients were extracted, and the included data are presented as relative ratio (RR) estimates with 95% confidence intervals (CIs) for all outcomes. The RRs of each study were pooled using a fixed or random effects model with Review Manager (the Cochrane Collaboration, Oxford, UK) version 5.3. The response rate to RT and the overall survival (OS) rate in neoadjuvant RT followed by hepatectomy and hepatectomy alone were measured.ResultsOne randomized and two non-randomized controlled trials with 302 patients were included. Most patients were classified as Child-Pugh A, and Type II and III PVTT were the most common types. After RT, 29 (22.8%) patients were evaluated as partial response (PR) and had a positive RT response, but nine (7.1%) had progressive disease (PD). Neoadjuvant RT followed by hepatectomy was received by 127 (42.1%) patients after excluding 15 (5.0%) patients with severe complications or PD after RT, and 160 (53.0%) patients received hepatectomy alone. In the randomized controlled trial (RCT), the 1-year OS rate in the neoadjuvant RT group and the surgery alone group was 75.2% and 43.1%, respectively (P<0.001). In the two non-randomized studies, a meta-analysis with a fixed effects model showed a longer OS in patients undergoing neoadjuvant RT followed by hepatectomy compared with hepatectomy alone at 1-year follow-up (RR =2.02; 95% CI: 1.45–2.80; P<0.0001).ConclusionsThis systematic review showed that neoadjuvant RT followed by hepatectomy in patients with resectable HCC and PVTT was associated with a longer OS than patients who received hepatectomy alone.     

经皮微波或射频消融肝实质分隔联合门静脉栓塞计划性肝切除术治疗余肝体积不足肝癌及胆管癌3例报告

目的 探讨经皮微波或射频消融肝实质分隔联合门静脉栓塞计划性肝切除术（percutaneous microwave/radiofrequency ablation liver partition and portal vein embolization for planned hepatectomy,PAPEP）替代联合肝脏分隔和门静脉结扎的二步肝切除术（associating liver partition and portal vein ligation for staged hepatectomy, ALPPS）治疗剩余肝体积（future liver remnant,FLR）不足肝癌和胆管癌的可行性和安全性。方法 回顾性分析2015年7-9月浙江省人民医院肝胆胰外科应用PAPEP治疗FLR不足的2例原发性肝癌和1例肝门部胆管癌的临床资料。先超声引导下经皮微波消融分隔预留侧和切除侧肝实质（percutaneous microwave ablation liver partition,PMA）,PMA后1~3 d行门静脉栓塞术（portal vein embolization,PVE）,PVE后10~13 d测量FLR,术前系统评估后限期肝切除术：2例肝癌分别行肝右三叶和右尾叶切除术、扩大右半肝切除术,1例肝门部胆管癌行肝右三叶和尾叶切除、肝肠内引流术。结果 PMA前3例标准全肝体积（standard liver volume,SLV）分别为1231.2mL、1202.9mL、1217.1mL,FLR分别为355.6 mL、383.4 mL、385.0 mL,FLR/SLV分别为28.9%、31.9%、31.6%。PMA时间118~132 min, PVE时间158~180 min,PMA或PVE术后病人低热经对症处理好转,肝功能无明显变化。PMA+PVE后10~13 d FLR分别为502.1 mL、527.4 mL、476.3 mL,较术前分别增大41.2%、37.6%、23.7%。肝切除术时间230~440 min,术中出血120~1800 mL。肝门部胆管癌术后并发膈下脓肿,经穿刺后治愈;1例肝癌术后并发腹水、黄疸,经内科治疗后治愈,术后住院时间15~40 d。 结论 PAPEP有望代替ALPPS治疗剩余肝体积不足的肝癌或肝门部胆管癌。     

Sequential arterial and portal vein embolizations before right hepatectomy in patients with cirrhosis and hepatocellular carcinoma

BACKGROUND: Selective transarterial chemoembolization (TACE) and portal vein embolization (PVE) could improve the rate of hypertrophy of the future liver remnant (FLR) in patients with chronic liver disease. This study evaluated the feasibility and efficacy of this combined procedure. METHODS: Between November 1998 and October 2004, 36 patients with cirrhosis and hepatocellular carcinoma underwent right hepatectomy after PVE. Additional TACE preceded PVE by 3-4 weeks in 18 patients (TACE+PVE group) and the remaining 18 patients had PVE alone (PVE group). RESULTS: PVE was well tolerated in all patients. The mean increase in percentage FLR volume was significantly higher in the TACE+PVE group than in the PVE group (mean(s.d.) 12(5) versus 8(4) percent; P=0.022). The rate of hypertrophy was more than 10 percent in 12 patients in the TACE+PVE group and in five who had PVE alone (P=0.044). Duration of surgery, blood loss, incidence of liver failure and mortality (two patients in each group) were similar in the two groups. None of the 17 patients with an increase in FLR volume of more than 10 percent died, whereas there were four deaths among 19 patients with a smaller increase. The incidence of complete tumour necrosis was significantly higher in the TACE+PVE group (15 of 18 versus one of 18; P<0.001), with a higher 5-year disease-free survival rate (37 versus 19 percent; P=0.041). CONCLUSION: Sequential TACE and PVE before operation increases the rate of hypertrophy of the FLR and leads to a high rate of complete tumour necrosis associated with longer recurrence-free survival.     

Characteristics and outcomes of hepatocellular carcinoma patients with macrovascular invasion following surgical resection: a meta-analysis of 40 studies and 8,218 patients

BackgroundGuidelines recommend that hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) and/or hepatic vein tumor thrombosis (HVTT) should undergo systemic therapy. However, recent data suggest that surgical resection may be beneficial in selected cases, but outcomes are heterogenous. We aimed to estimate pooled overall survival (OS), recurrence free survival (RFS) and complication rates in HCC patients with macrovascular invasion (MVI) following surgical resection.MethodsIn this systematic review and meta-analysis, two investigators independently searched PubMed, Embase, and Cochrane databases from inception to Nov 10, 2020, without language restrictions, for studies reporting outcomes of adult HCC patients with MVI who underwent liver resection with curative intent.ResultsWe screened 8,598 articles and included 40 studies involving 8,218 patients. Among all patients with MVI, the pooled median OS was 14.39 months [95% confidence interval (CI): 10.99–18.84], 1-year OS was 54.47% (95% CI: 46.12–62.58%) and 3-year OS was 23.20% (95% CI: 16.61–31.42%). Overall, 1- and 3-year RFS were 27.70% (95% CI: 21.00–35.57%) and 10.06% (95% CI: 6.62–15.01%), respectively. Among patients with PVTT, median OS was 20.41 months in those with segmental/2nd order involvement compared to 12.91 months if 1st order branch was involved and 6.41 months if the main trunk was involved. The pooled rate of major complications was 6.17% (95% CI: 3.53–10.56%).ConclusionsOverall median survival was 14.39 months for HCC patients with MVI following resection. Median survival was higher in PVTT with segmental/2nd order involvement at 20.41 versus 6.41 months if the main trunk was involved.     

Preoperative portal vein embolization for extended hepatectomy

OBJECTIVE: To examine the authors' experience with preoperative ipsilateral portal vein embolization (PVE) and assess its role in extended hepatectomy. SUMMARY BACKGROUND DATA: Extended hepatectomy (five or more liver segments) has been associated with higher complication rates and increased postoperative liver dysfunction than have standard hepatic resections involving lesser volumes. Recently, PVE has been used in patients who have a predicted (postresection) future liver remnant (FLR) volume less than 25% of total liver volume in an attempt to increase the FLR and reduce complications. METHODS: Sixty patients from 1996 to 2002 were reviewed. Thirty-nine patients had PVE preoperatively. Eight patients who had PVE were not resected either due to the discovery of additional unresectable disease after embolization but before surgery (n = 5) or due to unresectable disease at surgery (n = 3). Therefore, 31 patients who had PVE subsequently underwent extended hepatic lobectomy. A comparable cohort of 21 patients who had an extended hepatectomy without PVE were selected on the basis of demographic, tumor, and liver volume characteristics. Patients had colorectal liver metastases (n = 30), hepatocellular carcinoma (n = 15), Klatskin tumors (n = 9), peripheral cholangiocarcinoma (n = 3), and other tumors (n = 3). The 52 resections performed included 42 extended right hepatectomies, 6 extended left hepatectomies, and 4 right hepatectomies extended to include the middle hepatic vein and the caudate lobe but preserving the majority of segment 4. Concomitant vascular reconstruction of either the inferior vena cava or hepatic veins was performed in five patients. RESULTS: There were no differences between PVE and non-PVE groups in terms of tumor number, tumor size, tumor type, surgical margin status, complexity of operation, or perioperative red cell transfusion requirements. The predicted FLR was similar between PVE and non-PVE groups at presentation. After PVE the FLR was higher than in the non-PVE group. No complications were observed after PVE before resection. There was no difference in postoperative mortality, with one death from liver failure in the non-PVE group and no operative mortality in the PVE group. Postoperative peak bilirubin was higher in the non-PVE than the PVE group, as were postoperative fresh-frozen plasma requirements. Liver failure (defined as the development of encephalopathy, ascites requiring sustained diuretics or paracentesis, or coagulopathy unresponsive to vitamin K requiring fresh-frozen plasma after the first 24 hours postresection) was higher in the non-PVE patients than the PVE patients. The hospital stay was longer in the non-PVE than the PVE group. CONCLUSIONS: Preoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.     

联合肝脏离断和门静脉结扎的二步肝切除术在肝脏肿瘤治疗中的应用

联合肝脏离断和门静脉结扎的二步肝切除术（ALPPS）是近年提出的一种手术方式,分两次完成,第1次手术包括门静脉结扎、在待切除肝和需保留肝之间离断肝实质,待剩余肝脏体积增大后再行第2次手术切除病肝。ALPPS主要目的是使剩余肝脏体积快速增长,为那些原来不能切除的肝脏恶性肿瘤的患者提供可根治性切除的机会。本文综述了近几年ALPPS方面的研究,从演变过程、手术方法、适用范围、存在争论的问题和近几年的研究现状等方面进行了总结和分析,并对以后的发展方向提出了展望。     

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与采用不同栓塞材料PVE对肝再生及手术切除率影响研究

目的 比较不同栓塞材料的门静脉栓塞术（PVE）与联合肝脏分隔和门静脉结扎的二步肝切除术（ALPPS）对剩余肝体积（FLR）增长速率的影响,比较各组FLR的增长速率,二期手术切除率、术中数据和术后并发症。方法 采用单中心、前瞻性、非随机对照的对比研究。2014年11月至2019年12月,海军军医大学第三附属医院共126例因FLR不足导致无法切除的肝细胞癌（HCC）或肝内胆管癌（ICC）病人,将其分为4组：ALPPS组及分别采用氰基丙烯酸正丁酯（NBCA）、微球、明胶海绵作为栓塞材料的PVE组。主要终点为FLR增长速率和二期手术切除率。结果 各组的手术切除例数及二期手术切除率分别为：ALPPS组38例（99.4%）,NBCA组32例（76.2%）,明胶海绵组20例（60.6%）,微球组10例（83.3%）。ALPPS组、NBCA组、微球组的FLR增长速率分别为15.1 mL/d,10.0 mL/d和 8.5 mL/d,均高于明胶海绵组（3.7 mL/d）。结论 采用NBCA及微球作为栓塞材料的PVE导致FLR增长速率低于ALPPS,两种栓塞材料的PVE二期手术切除率相当。使用NBCA作为栓塞材料的PVE其FLR增长速率高于微球,且这两种栓塞材料的栓塞效果均优于明胶海绵。     

Effect of preoperative portal vein embolization on major hepatectomy for advanced-stage hepatocellular carcinomas in injured livers: A preliminary report

With the aim of minimizing postoperative liver dysfunction and promoting increased resectability, we employed portal vein embolization (PVE). In this study, the effect of PVE on major hepatic resection for advanced-stage hepatocellular carcinoma (HCC) in injured livers was evaluated. PVE was performed prior to hepatectomy in 13 patients with stage III and IV HCCs. Following PVE, right trisegmentectomy was performed in 3 patients, extended right lobectomy in 3 and right lobectomy in 7. To evaluate the effect of PVE, the changes in liver functional capacity and estimated remnant liver volume (ERLV), determined by computed tomography, were examined before and after PVE. The operative morbility, mortality, and survival rates after hepatectomy were also assessed. By 2 weeks after PVE, ERLV had increased in all patients, by an average of 28%, and the mean resection rates had decreased from 70.0% to 62.2%. Postoperatively, the 30-day mortality rate was 15.3%, and the 1- and 2-year survival rates were 69% and 46%, respectively. The results of this study indicate that resectability can be increased, and major hepatectomy can be made safer by employing PVE preoperatively, in view of the fact that major hepatectomy was not considered feasible without PVE in these patients.     

One or two-stage hepatectomy combined with portal vein embolization for initially nonresectable colorectal liver metastases

BACKGROUND: Portal vein embolization (PVE), proposed to induce contralateral hepatic hypertrophy before major hepatectomy, carries some negative side effects since growth rate of metastases in the future remnant liver (RL) can be more rapid than that of nontumoral liver parenchyma. Therefore, metastases in the RL should be ideally resected before PVE, and a major hepatectomy can then be performed after PVE in patients with multiple bilobar colorectal liver metastases (MBLM). The aim of this study was to assess feasibility and outcome in patients with initially unresectable colorectal liver metastases treated by a one- or two-stage hepatectomy procedure (TSHP) combined with PVE. PATIENTS AND METHODS: From December 1996 to December 1999, 180 patients with colorectal liver metastases underwent hepatectomy. During the same period, 18 were initially considered as unresectable. TSHP combined with PVE was attempted for 7 patients (group A) among those with MBLM, and a one-stage hepatectomy after PVE was attempted in another group of 11 patients (group B) among those with non-MBLM. RESULTS: Nonanatomical resections for left liver metastases were performed as a first stage without any complications in group A. A right hepatectomy (RH) was performed in 5 patients in group A (feasibility = 71%). In group B, 7 of the 11 patients underwent a RH or an extended RH after PVE (feasibility = 64%). Postoperative complications rate did not differ between group A and B. Mortality was nil. Three-year survival rate was 53% in group A and 100% in group B. CONCLUSIONS: These results suggest that one- or two-stage hepatectomy combined with PVE can be applied safely to selected patients initially considered as unresectable. Three-year survival was similar to that observed in patients with initially resectable liver metastases.     

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。     

A new staging system for hepatocellular carcinoma associated with portal vein tumor thrombus

BackgroundA new staging system for patients with hepatocellular carcinoma (HCC) associated with portal vein tumor thrombus (PVTT) was developed by incorporating the good points of the BCLC classification of HCC, and by improving on the currently existing classifications of HCC associated with PVTT.MethodsUnivariate and multivariate analysis with Wald χ² test were used to determinate the clinical prognostic factors for overall survival (OS) in patients with HCC and PVTT in the training cohort. Then the conditional inference trees analysis was applied to establish a new staging system.ResultsA training cohort of 2,179 patients from the Eastern Hepatobiliary Surgery Hospital and a validation cohort of 1,550 patients from four major liver centers in China were enrolled into establishing and validating a new staging system. The system was established by incorporating liver function, general health status, tumor resectability, extrahepatic metastasis and extent of PVTT. This staging system had a good discriminatory ability to separate patients into different stages and substages. The median OS for the two cohorts were 57.1 (37.2–76.9), 12.1 (11.0–13.2), 5.7 (5.1–6.2), 4.0 (3.3–4.6) and 2.5 (1.7–3.3) months for the stages 0 to IV, respectively (P<0.001) in the training cohort. The corresponding figures for the validation cohort were 6.4 (4.9–7.9), 2.8 (1.3–4.4), 10.8 (9.3–12.4), and 1.5 (1.3–1.7) months for the stages II to IV, respectively (P<0.001). The mean survival for stage 0 to 1 were 37.6 (35.9–39.2) and 30.4 (27.4–33.4), respectively (P<0.001).ConclusionsA new staging system was established which provided a good discriminatory ability to separate patients into different stages and substages after treatment. It can be used to supplement the other HCC staging systems.     

肝脏离段联合门静脉结扎二期肝切除术的研究进展

术后肝功能衰竭一直是肝脏外科医生面临的一大难题,而术后肝功能衰竭往往与(FLR)不足直接相关。肝脏离段联合门静脉结扎二期肝切除术(ALPPS)作为能在短期内使FLR快速增长的一项革新技术,为因FLR不足而无法施行根治性手术的患者带来了希望。但在许多大型中心先后报道ALPPS的高病死率后,如何正确把握ALPPS手术适应证及对传统ALPPS术式的改进显得尤为重要。笔者对ALPPS促进FLR增生机制、ALPPS的病例选择、ALPPS术式的争议及目前基于经典ALPPS衍生术式的最新进展进行综述。     

门静脉结扎与栓塞在肝切除术中应用的Meta分析

目的 系统评价门静脉结扎（PVL）和门静脉栓塞（PVE）后肝切除前剩余肝体积（FLR）增长率和其他围手术期结局指标。方法 检索相关数据库,收集关于PVL与PVE在肝切除术中应用的随机对照试验（RCT）或临床对照试验（CCT）,提取相关数据后,采用RevMan5.3软件进行Meta分析。结果 最终纳入8项研究,共438例病人。Meta分析结果显示：PVE组与PVL组FLR增长率、术后病死率、肝功能衰竭和并发症等方面差异无统计学意义。然而,联合肝脏分隔和门静脉结扎的二步肝切除术（ALPPS）较PVE能明显增加FLR。结论 PVL与PVE在肝切除术中有着相似的FLR增长率、术后病死率和并发症。ALPPS 相比PVE能明显加速FLR增长。     

门静脉栓塞术在肝脏肿瘤二期切除中的应用

目的 探讨门静脉栓塞术在肝脏肿瘤二期切除过程中的作用与安全性。方法 分析总结5例难以一期切除肝脏肿瘤,先行门静脉栓塞术后再行二期肿瘤切除患者的临床资料。所有患者均采用B超及DSA引导下经皮肝门静脉左支穿刺法对门静脉右支进行栓塞。检测门静脉栓塞术后肝功能及肝叶体积变化,总结门静脉栓塞与肿瘤二期切除手术成功率。结果 5例患者均成功实施PVE术,术后出现一过性的肝功能减退,经保肝治疗短期恢复,未栓塞侧肝脏体积代偿性增大明显,达到预期效果;所有病例均顺利完成二期肝叶切除术,术后肝功能良好。结论 门静脉栓塞术成功率高、安全可行,对侧肝脏代偿性增大明显,达到预期目的,使得难以一期切除的肝脏肿瘤可以切除,从而提高肝脏肿瘤的切除率。     

Greater hypertrophy can be achieved with associating liver partition with portal vein ligation for staged hepatectomy compared to conventional staged hepatectomy,but with a higher price to pay?

Background

Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) and conventional staged hepatectomy (CSH) are options for patients with unresectable liver tumors due to insufficient future liver remnant (FLR).

The role of associating liver partition and portal vein ligation for staged hepatectomy in the management of patients with colorectal liver metastasis

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach emerged as a promising surgical strategy for rapid and large hypertrophy of the future liver remnant (FLR) when a major liver resection is necessary. Colorectal liver metastasis (CRLM) is their main indication. However, the promising results published so far, are very difficult to interpret since they usually focus on the technique and not on the underlying disease. Moreover, they are usually made up of complex populations, which received different chemotherapy schemes, with the ALPPS technical variations implemented over time and without consistent long-term follow-up results as well. Whereby, its role in CRLM should be analyzed as carefully as possible to indicate and select the best candidates who will benefit the most from this approach. We conducted a computerized search using PubMed and Google Scholar for reports published so far, using mesh headings and keywords related to the ALPPS and CRLM.     

Adjuvant transcatheter arterial chemoembolization improves efficacy of hepatectomy for patients with hepatocellular carcinoma and portal vein tumor thrombus

Purpose

To study the value of postoperative transcatheter arterial chemoembolization (TACE) to improve the efficacy of hepatectomy and tumor thrombus removal for patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT).

Experimental design

From January 1996 to December 2004, 126 patients with HCC and PVTT were randomly assigned into 2 groups: a control group and a TACE group. The control group underwent liver resection combined with PVTT removal, and the TACE group underwent liver resection combined with adjuvant TACE after surgery. Survival time in the 2 groups was studied.

Results

The 2 groups were comparable with regard to all clinicopathologic data. The median survival time was 13 months (95% confidence interval [CI] 6.25 to 19.75 months) for the TACE group and 9 months (95% CI 6.90 to 11.10 months) for the control group. Estimated survival rates for 1, 3 and 5 years were better in the TACE group (50.9%, 33.8%, 21.5%; respectively) than the control group (33.3%, 17.0%, 8.5%, respectively; log rank P = .0094).

Conclusions

Postoperative TACE enhances the effect of liver resection combined with PVTT removal for HCC patients with PVTT.