Gregor A. Stavrou

Current position of ALPPS in the surgical landscape of CRLM treatment proposals

The Authors summarize problems, criticisms but also advantages and indications regarding the recent surgical proposal of associating liver partition and portal vein ligation (PVL) for staged hepatectomy (ALPPS) for the surgical management of colorectal liver metastases. Looking at published data, the technique, when compared with other traditional and well established methods such as PVL/portal vein embolisation (PVE), seems to give real advantages in terms of volumetric gain of future liver remnant. However, major concerns are raised in the literature and some questions remain unanswered, preliminary experiences seem to be promising. The method has been adopted all over the world over the last 2 years, even if oncological long-term results remain unknown, and benefit for patients is questionable. No prospective studies comparing traditional methods (PVE, PVL or classical 2 staged hepatectomy) with ALPPS are available to date. Technical reinterpretations of the original method were also proposed in order to enhance feasability and increase safety of the technique. More data about morbidity and mortality are also expected. The real role of ALPPS is, to date, still to be established. Large clinical studies, even if, for ethical reasons, in well selected cohorts of patients, are expected to better define the indications for this new surgical strategy.

Nonoperative Management of Tracheobronchial Injuries in Severely Injured Patients

PurposeA rupture of the airway due to blunt chest trauma is rare, and treatment can prove challenging. Many surgeons suggest operative management for these kinds of injuries. Nonoperative therapy is reported only in exceptional cases. But there is still a lack of evidence from which to recommend surgical repair of these injuries as the first choice procedure.MethodsWe retrospectively analyzed the records of 92 multiple injured patients admitted to our trauma department between July 2002 and July 2003 for the incidence and management of tracheobronchial rupture (TBR).ResultsFive (5.4%) of 92 patients suffered from tracheobronchial injuries. The mean injury severity score was 38. There were three male and two female patients, with a mean age of 23 years. All patients had lesions <2 cm in size and were treated nonoperatively. One patient died from multiorgan failure, but the others recovered from TBR uneventfully. One patient developed acute pneumonia as a result of respirator therapy, but none of the patients had mediastinitis or tracheal stenosis within 3 months after injury.ConclusionWe believe that surgical treatment is not mandatory in patients with small to moderate ruptures, and such aggressive treatment may even have adverse effects, especially in patients with multiple injuries.

The ALPPS Risk Score: Avoiding Futile Use of ALPPS.

Objectives: To create a prediction model identifying futile outcome in ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) before stage 1 and stage 2 surgery. Background: ALPPS is a 2-stage hepatectomy, which incorporates parenchymal transection at stage 1 enabling resection of extensive liver tumors. One of the major criticisms of ALPPS is the associated high mortality rate up to 20%. Methods: Using the International ALPPS Registry, a risk analysis for futile outcome (defined as 90-day or in-hospital mortality) was performed. Futility was modeled using multivariate regression analysis and a futility risk score formula was computed on the basis of the relative size of logistic model regression coefficients. Results: Among 528 ALPPS patients from 38 centers, a futile outcome was observed in 47 patients (9%). The pre-stage 1 model included age 67 years or older [odds ratio (OR) = 5.7], and tumor entity (OR = 3.8 for biliary tumors) as independent predictors of futility from multivariate analysis. For the pre-stage 1 model scores of 0, 1, 2, 3, 4 and 5 were associated with futile risk of 2.7%, 4.9%, 8.6%, 15%, 24%, and 37%. The pre-stage 2 model included major complications (grade ≥ 3b) after stage 1 (OR = 3.4), serum bilirubin (OR = 4.4), serum creatinine (OR = 5.4), and cumulative pre-stage 1 risk score (OR = 1.9). The model predicted futility risk of 5%, 10%, 20%, and 50% for patients with scores of 3.9, 4.7, 5.5, and 6.9, respectively. Conclusions: Both models have an excellent prediction to assess the individual risk of futile outcome after ALPPS surgery and can be used to avoid futile use of ALPPS.

Integration of 3D Volumetry, Portal Vein Transection and In Situ Split Procedure: A New Surgical Strategy for Inoperable Liver Metastasis

IntroductionThe purpose of this study was to report on the feasibility of integrating 3D preoperative volumetry, portal vein transection and in situ split procedure. A 54-year-old female with now resectable colorectal liver metastasis (CRLM) (segments III, IVb, V–VIII) underwent a two-staged procedure.MethodsSegment III resection, right portal vein transection and an in situ split procedure (first stage) after 3D volumetry based on CT data and a right trisegmentectomy (second stage) were performed. RO resection of metastases was achieved, and the postoperative course was uneventful.ConclusionThe proposed strategy seems to be a promising method to achieve higher resectability rates in CRLM patients.

How much liver needs to be transected in ALPPS? A translational study investigating the concept of less invasiveness.

BACKGROUND ALPPS induces rapid liver hypertrophy after stage‐1 operation, enabling safe, extended resections (stage‐2) after a short period. Recent studies have suggested that partial transection at stage‐1 might be associated with a better safety profile. The aim of this study was to assess the amount of liver parenchyma that needs to be divided to achieve sufficient liver hypertrophy in ALPPS. METHODS In a bi‐institutional, prospective cohort study, nonfibrotic patients who underwent ALPPS with complete (n = 22) or partial (n = 23) transection for colorectal liver metastases were analyzed and compared with an external ALPPS cohort (n = 23). A radiologic tool was developed to quantify the amount of parenchymal transection. Liver hypertrophy and clinical outcome were compared between both techniques. The relationship of partial transection and hypertrophy was investigated further in an experimental murine model of partial ALPPS. RESULT The median amount of parenchymal transection in partial ALPPS was 61% (range, 34–86%). The radiologic method correlated poorly with the intraoperative surgeons estimation (rS = 0.258). Liver hypertrophy was equivalent for the partial ALPPS, ALPPS, and external ALPPS cohort (64% vs 60% vs. 64%). Experimental data demonstrated that partial transection of at least 50% induced comparable hypertrophy (137% vs 156%) and hepatocyte proliferation compared to complete transection. CONCLUSION The study provides clinical and experimental evidence that partial liver partition of at least 50% seems to be equally effective in triggering volume hypertrophy as observed with complete transection and can be re recommended as less invasive alternative to ALPPS.

Risk Adjustment in ALPPS Is Associated With a Dramatic Decrease in Early Mortality and Morbidity

Objective: To longitudinally assess whether risk adjustment in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) occurred over time and is associated with postoperative outcome. Background: ALPPS is a novel 2-stage hepatectomy enabling resection of extensive hepatic tumors. ALPPS has been criticized for its high mortality, which is reported beyond accepted standards in liver surgery. Therefore, adjustments in patient selection and technique have been performed but have not yet been studied over time in relation to outcome. Methods: ALPPS centers of the International ALPPS Registry having performed ≥10 cases over a period of ≥3 years were assessed for 90-day mortality and major interstage complications (≥3b) of the longitudinal study period from 2009 to 2015. The predicted prestage 1 and 2 mortality risks were calculated for each patient. In addition, questionnaires were sent to all centers exploring center-specific risk adjustment strategies. Results: Among 437 patients from 16 centers, a shift in indications toward colorectal liver metastases from 53% to 77% and a reverse trend in biliary tumors from 24% to 9% were observed. Over time, 90-day mortality decreased from initially 17% to 4% in 2015 (P = 0.002). Similarly, major interstage complications decreased from 10% to 3% (P = 0.011). The reduction of 90-day mortality was independently associated with a risk adjustment in patient selection (P < 0.001; OR: 1.62; 95% CI: 1.36–1.93) and using less invasive techniques in stage-1 surgery (P = 0.019; OR: 0.39; 95% CI: 0.18–0.86). A survey indicated risk adjustment of patient selection in all centers and ALPPS technique in the majority (80%) of centers. Conclusions: Risk adjustment of patient selection and technique in ALPPS resulted in a continuous drop of early mortality and major postoperative morbidity, which has meanwhile reached standard outcome measures accepted for major liver surgery.

ALPPS and simultaneous right hemicolectomy - step one and resection of the primary colon cancer.

BackgroundResection of the liver is often limited due to the volume of the parenchyma. To address this problem, several approaches to induce hypertrophy were developed. Recently, the ‘associating liver partition and portal vein ligation for staged hepatectomy’ (ALPPS) procedure was introduced and led to rapid hypertrophy in a short interval. Additionally to the portal vein occlusion, the parenchyma is transected, which disrupts the inter-parenchymal vascular connections.Since the first description of the ALPPS procedure, various reports around the world were published. In some cases, due to the high morbidity and mortality, a decent oncologic algorithm is not deliverable in a timely manner. If a patient is to be treated with a liver-first approach, the resection of the primary could sometimes be severely protracted. To overcome the problem, a simultaneous resection of the primary tumor and step one of ALPPS were performed.Case presentationA 73-year-old male patient underwent portal vein embolization (PVE) after suffering from a synchronous hepatic metastasized carcinoma of the right colic flexure in order to perform a right trisectionectomy. Sufficient hypertrophy could not be obtained by PVE. Thus a ‘Rescue-ALPPS’ was undertaken. During step one of ALPPS, we simultaneously performed a right hemicolectomy. The postoperative course after the first step was uneventful, and sufficient hypertrophy was achieved.ConclusionIn order to achieve a macroscopic disease-free state and lead the patient as soon as possible to the oncologic path (with, for example, chemotherapy), sometimes a simultaneous resection of the primary with step one of the ALPPS procedure seems justified. A resection of the primary with step two is not advisable, due to the high morbidity and mortality after this step. This case shows that a simultaneous resection is feasible and safe. Whether other locations of the primary should be treated this way must be part of further investigations.

Laparoscopic Resections for Hilar Cholangiocarcinomas: A Critical Appraisal

caudate lobe or to make a 100% prevision of hepatic resection only based on preoperative data. On the contrary, it is known that the caudate lobe is involved in nearly all patients with cholangiocarcinoma [5] . The decision to resect or not the caudate lobe has nothing to do with the biliary confluence’s distance from the liver but is related to lymphatic drainage of both hepatic ducts after bifurcation. Therefore, we were surprised to read that in Bismuth II no caudate resection was performed because of technical difficulties thus leading to a lack of radicality. Moreover, the tendency of most authors is to perform caudate resection at least in those tumors (Bismuth II) and, of course, also a hepatic resection [3, 6] . Many authors have shown better results in terms of survival in hilar cholangiocarcinomas by combining biliary and hepatic resections [2, 7] . Furthermore, the authors gave an accurate description of the surgical approach, confirming the principal of a supraduodenal dissection at the beginning of the procedure, as is usually performed in open surgery. However, the key point of this initial step is the determination of resectability that is usually established by the surgeon after a careful palpation of the hilus and maybe also dissection and surgical exposition of hilar elements. Dear Sir We read with great interest the article ‘Laparoscopic resection of Bismuth type I and II hilar cholangiocarcinoma: an audit of 14 cases from two institutions’ by Yu et al. [1] that appeared in this journal some weeks ago, referring to one of the first worldwide experiences for surgically managing hilar cholangiocarcinomas in laparoscopy. Despite considerations about the technical feasibility of surgical resections, we have to observe that the authors presuppose, for their selection criteria of patients to undergo laparoscopic surgical procedure, a 100% success rate of preoperative staging and classification of cholangiocarcinomas; it is well known that preoperative staging can exactly determine real pathological conditions in no more than 80% [2] . In fact, only 40–50% of patients explored with curative intent are ultimately resectable [3] . As mentioned by other authors, about 30% of patients, despite all preoperative resources, receive an underestimation of tumor extension [4] . There are some questions about caudate lobe resection and anatomical selection criteria for resection; while the authors reported in their article ‘We examined extrahepatic anatomy carefully...’, there are still no published data concerning the decision to resect or not the Published online: July 20, 2011

The LiverSurgeryTrainer: training of computer-based planning in liver resection surgery

AbstractPurpose The training of liver surgeons depends on local conditions such as the specialization of the clinic, the spectrum of cases, and the instructing surgeons. We present the LiverSurgeryTrainer a software application to support the training of prospective surgeons in preoperative decision making. Methods The LiverSurgeryTrainer visualizes radiological images, volumetric information, and interactive 3D models of patients’ liver anatomy. In addition, it provides special interaction techniques and tools to perform individual resections on the training data. To assess the correctness of decisions made by the learner, comments and decisions from experienced liver surgeons are provided for each case. To complete the case, additional material concerning the actual surgery (e.g., videos, reports) is presented. The application workflow is derived from a scenario-based design process and is based on an instructional design model. Results The LiverSurgeryTrainer was evaluated in several steps. A formative usability evaluation identified workflow and user interface flaws that were resolved in further development process. A summative evaluation shows the improvement of the LiverSurgeryTrainer in nearly all analyzed aspects. First results of a learning success evaluation show that learners experience a learning effect. Conclusion Our training system allows surgeons to train procedures and interaction techniques for computer-based planning of liver interventions. The evaluations showed acceptance and usability.

Anterior approach liver resection with the liver hanging maneuver. Technique and indications

The anterior approach liver resection has advantages compared to conventional liver resection. Mobilization during conventional liver resection may cause local pressure on the tumor which could lead to tumor cell dissemination or even to tumor rupture. Furthermore, hemodynamic parameters tend to deteriorate during mobilization due to compression or twisting of the inferior vena cava. In addition, the left liver lobe often is compressed which can lead to tissue damage of the residual parenchyma. The risk of these complications can be reduced by the anterior approach technique which is facilitated by the so-called liver hanging maneuver. Appropriate indications for this technique are large tumors of the right liver lobe, tumors with infiltration of the right hepatic vein and infiltration of the vena cava from the right side, tumors with infiltration of the diaphragm and tumors of the right lobe after previous resections of the right lobe.