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Is there still a room to improve the safety of ALPPS procedure? A new technical note
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ScienceDirect EJSO xx (2015) 1e2
www.ejso.com
Correspondence
Is there still a room to improve the safety of ALPPS procedure? A new technical note There is increasing evidence that Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has acceptable morbidity and mortality and consequently may be an alternative to conventional twostage or used as rescue ALPPS in cases of failure of a portal vein embolization. In a recent study,1 we showed that the rate of morbi-mortality after the first stage was high in the setting of ALPPS, far from that reported for conventional two-stage hepatectomy. This was due to the high rate of local technical complications in association with systemic complications, directly impacting the ALPPS outcome: biliary fistula, segment IV necrosis, adhesions or transitory liver dysfunction. Patients with major complications after the first stage were at high risk of death following the second stage. Besides the need for a better selection of patients, e.g. young patients who can stand such demanding two-stage operation or exclusion of hilar cholangiocarcinoma,2 we feel that there is still a room to improve the technical aspect of ALPPS procedure, in order to avoid the main local complications. First, to prevent ischemic necrosis of segment 4, Hernandez-Alejandro et al.,3 minimized dissection of the hepatoduodenal ligament to preserve arterial supply to segment 4 and the bile duct, and further preserved the middle hepatic vein. Whether Radio-frequency-assisted Liver Partition with Portal Vein Ligation (RALPP) could preserve the segment IV from necrosis need to be determined.4 Second, to decrease the rate of biliary complications, biliary structures should be preserved as much as possible during the first stage. Indeed, it is now established that bile duct obstruction e although initially believed to induce atrophy of the nondrained liver and trigger compensatory controlateral hypertrophy of the future remnant livere is associated with a high rate of biliary complications and should be abandoned. Moreover, the cut surfaces of the two hemilivers have to be thoroughly and similarly treated during parenchymal splitting, with special focus on the segment
DOI of original article: http://dx.doi.org/10.1016/j.ejso.2015.06.013
IV bile duct that is particularly exposed to injury and leakage in the transection plane. Third, small for size syndrome may occur early during the first stage, due to the sudden rise of portal vein flow in the future remnant liver.5 Although it is assumed that preoperative portal vein embolization could prepare the future remnant liver to stand this huge increase of portal vein flow, it did not alter the postoperative morbimortality in our series,1 possibly due to a lack of statistical power. Overall, partial ALPPS (>50% of the transection surface) may avoid most of these technical pitfalls and appeared to be safer than ALPPS despite achieving similar rapid hypertrophy.6 Last, some authors7 have recently proposed to postpone the second stage after 3 or more weeks of the first stage, far from potential systemic inflammatory stress provoked by the first procedure. While we have shown that the kinetic growth rate of the future remnant liver (i.e. mean volume increase per day) decreased significantly beyond 7 days after the first stage,1 we recently reported using inter-stages (99 m)Tc-mebrofenin hepatobiliary scintigraphy a drop in the total liver function after the first stage that could indeed prompt surgeon to delay the second stage.8 In this context, the use of a laparoscopic approach as well as devices to minimize interlobar and retrohepatic adhesions is crucial to decrease the poststage2 morbimortality, with preference for resorbable devices (avoiding the use of foreign bodies) such as acellular collagen membrane9 or a peritoneal patch, as reported here, in association with vessel identifications tags.9 Hence, solving the technical issues of ALPPS may achieve the 2a development stage of ALPPS recently proposed by Clavien and De Santibanes,10 as for any surgical innovation. Conflict of interest The authors have no conflict of interest. References 1. Truant S, Scatton O, Dokmak S, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): impact of the inter-stages course on morbi-mortality and implications for management. Eur J Surg Oncol 2015 May;41(5):674–82.
http://dx.doi.org/10.1016/j.ejso.2015.08.151 0748-7983/Ó 2015 Elsevier Ltd. All rights reserved. Please cite this article in press as: Truant S, Pruvot F-R, Is there still a room to improve the safety of ALPPS procedure? A new technical note, Eur J Surg Oncol (2015), http://dx.doi.org/10.1016/j.ejso.2015.08.151
2
Correspondence / EJSO xx (2015) 1e2
2. Schadde E, Ardiles V, Robles-Campos R, et al. Early survival and safety of ALPPS: first report of the International ALPPS Registry. Ann Surg 2014;260:829–36.. discussion 836e8. 3. Hernandez-Alejandro R, Bertens KA, Pineda-Solis K, Croome KP. Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases? Surgery 2015;157:194–201. 4. Gall TM, Sodergren MH, Frampton AE, et al. Radio-frequency-assisted Liver Partition with Portal vein ligation (RALPP) for liver regeneration. Ann Surg 2015;261:e45–6. 5. Vicente E, Quijano Y, Ielpo B, et al. Is “small for size syndrome” a relatively new complication after the ALPPS procedure? Updates Surg 2015 Jun 21. [Epub ahead of print]. 6. Petrowsky H, Gyori G, de Oliveira M, Lesurtel M, Clavien PA. Is partial-ALPPS safer than ALPPS? a single-center experience. Ann Surg 2015;261:e90–2. 7. Andriani OC. Long-term results with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Ann Surg 2012;256:e5.. author reply e16e9. 8. Truant S, Baillet C, Deshorgue AC, et al. Drop of total liver function in the inter-stages of the new ALPPS technique: analysis of the “auxiliary liver” by HIDA scintigraphy. Ann Surg 2015.. In Press.
9. Brustia R, Scatton O, Perdigao F, El-Mouhadi S, Cauchy F, Soubrane O. Vessel identifications tags for open or laparoscopic associating liver partition and portal vein ligation for staged hepatectomy. J Am Coll Surg 2013;217:e51–5. 10. Clavien PA, de Santibanes E. The ALPPS: time to explore!. Ann Surg 2012;256:e18–19.. author reply e16e9.
S. Truant* F-R. Pruvot Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, Lille, France *Corresponding author. Service de Chirurgie Digestive et Transplantation H^opital HURIEZ, Rue M. Polonovski CHU, Univ Nord de France, F-59000 Lille, France. Tel.: þ33 320 444260; fax: þ33 320 446364. E-mail address: [email protected] (S. Truant) Accepted 13 August 2015
Please cite this article in press as: Truant S, Pruvot F-R, Is there still a room to improve the safety of ALPPS procedure? A new technical note, Eur J Surg Oncol (2015), http://dx.doi.org/10.1016/j.ejso.2015.08.151
ScienceDirect EJSO xx (2015) 1e2
www.ejso.com
Correspondence
Is there still a room to improve the safety of ALPPS procedure? A new technical note There is increasing evidence that Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has acceptable morbidity and mortality and consequently may be an alternative to conventional twostage or used as rescue ALPPS in cases of failure of a portal vein embolization. In a recent study,1 we showed that the rate of morbi-mortality after the first stage was high in the setting of ALPPS, far from that reported for conventional two-stage hepatectomy. This was due to the high rate of local technical complications in association with systemic complications, directly impacting the ALPPS outcome: biliary fistula, segment IV necrosis, adhesions or transitory liver dysfunction. Patients with major complications after the first stage were at high risk of death following the second stage. Besides the need for a better selection of patients, e.g. young patients who can stand such demanding two-stage operation or exclusion of hilar cholangiocarcinoma,2 we feel that there is still a room to improve the technical aspect of ALPPS procedure, in order to avoid the main local complications. First, to prevent ischemic necrosis of segment 4, Hernandez-Alejandro et al.,3 minimized dissection of the hepatoduodenal ligament to preserve arterial supply to segment 4 and the bile duct, and further preserved the middle hepatic vein. Whether Radio-frequency-assisted Liver Partition with Portal Vein Ligation (RALPP) could preserve the segment IV from necrosis need to be determined.4 Second, to decrease the rate of biliary complications, biliary structures should be preserved as much as possible during the first stage. Indeed, it is now established that bile duct obstruction e although initially believed to induce atrophy of the nondrained liver and trigger compensatory controlateral hypertrophy of the future remnant livere is associated with a high rate of biliary complications and should be abandoned. Moreover, the cut surfaces of the two hemilivers have to be thoroughly and similarly treated during parenchymal splitting, with special focus on the segment
DOI of original article: http://dx.doi.org/10.1016/j.ejso.2015.06.013
IV bile duct that is particularly exposed to injury and leakage in the transection plane. Third, small for size syndrome may occur early during the first stage, due to the sudden rise of portal vein flow in the future remnant liver.5 Although it is assumed that preoperative portal vein embolization could prepare the future remnant liver to stand this huge increase of portal vein flow, it did not alter the postoperative morbimortality in our series,1 possibly due to a lack of statistical power. Overall, partial ALPPS (>50% of the transection surface) may avoid most of these technical pitfalls and appeared to be safer than ALPPS despite achieving similar rapid hypertrophy.6 Last, some authors7 have recently proposed to postpone the second stage after 3 or more weeks of the first stage, far from potential systemic inflammatory stress provoked by the first procedure. While we have shown that the kinetic growth rate of the future remnant liver (i.e. mean volume increase per day) decreased significantly beyond 7 days after the first stage,1 we recently reported using inter-stages (99 m)Tc-mebrofenin hepatobiliary scintigraphy a drop in the total liver function after the first stage that could indeed prompt surgeon to delay the second stage.8 In this context, the use of a laparoscopic approach as well as devices to minimize interlobar and retrohepatic adhesions is crucial to decrease the poststage2 morbimortality, with preference for resorbable devices (avoiding the use of foreign bodies) such as acellular collagen membrane9 or a peritoneal patch, as reported here, in association with vessel identifications tags.9 Hence, solving the technical issues of ALPPS may achieve the 2a development stage of ALPPS recently proposed by Clavien and De Santibanes,10 as for any surgical innovation. Conflict of interest The authors have no conflict of interest. References 1. Truant S, Scatton O, Dokmak S, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): impact of the inter-stages course on morbi-mortality and implications for management. Eur J Surg Oncol 2015 May;41(5):674–82.
http://dx.doi.org/10.1016/j.ejso.2015.08.151 0748-7983/Ó 2015 Elsevier Ltd. All rights reserved. Please cite this article in press as: Truant S, Pruvot F-R, Is there still a room to improve the safety of ALPPS procedure? A new technical note, Eur J Surg Oncol (2015), http://dx.doi.org/10.1016/j.ejso.2015.08.151
2
Correspondence / EJSO xx (2015) 1e2
2. Schadde E, Ardiles V, Robles-Campos R, et al. Early survival and safety of ALPPS: first report of the International ALPPS Registry. Ann Surg 2014;260:829–36.. discussion 836e8. 3. Hernandez-Alejandro R, Bertens KA, Pineda-Solis K, Croome KP. Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases? Surgery 2015;157:194–201. 4. Gall TM, Sodergren MH, Frampton AE, et al. Radio-frequency-assisted Liver Partition with Portal vein ligation (RALPP) for liver regeneration. Ann Surg 2015;261:e45–6. 5. Vicente E, Quijano Y, Ielpo B, et al. Is “small for size syndrome” a relatively new complication after the ALPPS procedure? Updates Surg 2015 Jun 21. [Epub ahead of print]. 6. Petrowsky H, Gyori G, de Oliveira M, Lesurtel M, Clavien PA. Is partial-ALPPS safer than ALPPS? a single-center experience. Ann Surg 2015;261:e90–2. 7. Andriani OC. Long-term results with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Ann Surg 2012;256:e5.. author reply e16e9. 8. Truant S, Baillet C, Deshorgue AC, et al. Drop of total liver function in the inter-stages of the new ALPPS technique: analysis of the “auxiliary liver” by HIDA scintigraphy. Ann Surg 2015.. In Press.
9. Brustia R, Scatton O, Perdigao F, El-Mouhadi S, Cauchy F, Soubrane O. Vessel identifications tags for open or laparoscopic associating liver partition and portal vein ligation for staged hepatectomy. J Am Coll Surg 2013;217:e51–5. 10. Clavien PA, de Santibanes E. The ALPPS: time to explore!. Ann Surg 2012;256:e18–19.. author reply e16e9.
S. Truant* F-R. Pruvot Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, Lille, France *Corresponding author. Service de Chirurgie Digestive et Transplantation H^opital HURIEZ, Rue M. Polonovski CHU, Univ Nord de France, F-59000 Lille, France. Tel.: þ33 320 444260; fax: þ33 320 446364. E-mail address: [email protected] (S. Truant) Accepted 13 August 2015
Please cite this article in press as: Truant S, Pruvot F-R, Is there still a room to improve the safety of ALPPS procedure? A new technical note, Eur J Surg Oncol (2015), http://dx.doi.org/10.1016/j.ejso.2015.08.151