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 sur...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.展开更多
Objective: To analyze the volumetric modifications of the non tumourous part of the liver when liver metastases (LM) decrease under chemotherapy. Methods: Patients were highly selected based on the following criteria:...Objective: To analyze the volumetric modifications of the non tumourous part of the liver when liver metastases (LM) decrease under chemotherapy. Methods: Patients were highly selected based on the following criteria: multiple bilateral large colorectal LM, response of LM attaining at least 85% under chemotherapy. The volumes and ratios of the whole liver, of the LM, and mainly of the non tumourous (normal) part of the liver, were measured on CT scan before and after chemotherapy. Results: Only ten (5%) among 198 treated patients were eligible. Nine of them had received intra-arterial chemotherapy. Metastatic involvement was initially 34% before chemotherapy (range: 13% - 75%), and was 5% (range: 1% - 25%) after chemotherapy. The whole liver volume decreased by 41% (range: 23% - 68%) after chemotherapy. The non metastatic liver (volume and ratio) decreased after chemotherapy in 6 patients and increased in 4 patients. The volume and ratio increased in the 4 patients whose disease initially exhibited the highest metastatic involvement (p = 0.01). Conclusion: The volume of the non metastatic part of the liver varied slightly under standard chemotherapy. Intra-arterial chemotherapy induces dramatic responses, but also liver injury which impairs liver regeneration. However increasing volumes were observed when initial tumour involvement was major.展开更多
肝脏是结直肠癌血行转移最主要的靶器官,结直肠癌肝转移（colorectal cancer liver metastases）是结直肠癌治疗的重点和难点之一。约15%~25%结直肠癌病人在确诊时即合并有肝转移,另有15%~25%的病人将在行结直肠癌原发灶根治术后发生肝...肝脏是结直肠癌血行转移最主要的靶器官,结直肠癌肝转移（colorectal cancer liver metastases）是结直肠癌治疗的重点和难点之一。约15%~25%结直肠癌病人在确诊时即合并有肝转移,另有15%~25%的病人将在行结直肠癌原发灶根治术后发生肝转移,其中绝大多数（80%~90%）的肝转移灶无法获得根治性切除。展开更多
第一部分诊疗指南 肝脏是结直肠癌血行转移最主要的靶器官，结直肠癌肝转移（colorectal cancer liver metastases）是结直肠癌治疗的重点和难点之一。15％-25％的结直肠癌病人在确诊时即合并肝转移，另有15％-25％的病人将在结直肠癌...第一部分诊疗指南 肝脏是结直肠癌血行转移最主要的靶器官，结直肠癌肝转移（colorectal cancer liver metastases）是结直肠癌治疗的重点和难点之一。15％-25％的结直肠癌病人在确诊时即合并肝转移，另有15％-25％的病人将在结直肠癌根治术后发生肝转移，其中绝大多数（80％-90％）的肝转移灶初始无法获得根治性切除。展开更多
BACKGROUND： Associating liver partition and portal vein ligation for staged hepatectomy （ALPPS） has recently been developed to induce rapid liver hypertrophy and reduce posthepatectomy liver failure in patients wit...BACKGROUND： Associating liver partition and portal vein ligation for staged hepatectomy （ALPPS） has recently been developed to induce rapid liver hypertrophy and reduce posthepatectomy liver failure in patients with insufficient future liver remnant （FLR）. ALPPS is still considered to be in an early developmental phase because surgical indications and techniques have not been standardized. This article aimed to review the current role and future developments of ALPPS. DATA SOURCES： Studies were identified by searching MED- LINE and PubMed for articles from January 2007 to October 2016 using the keywords ＂associating liver partition and portal vein ligation for staged hepatectomy＂ and ＂ALPPS＂ Addi- tional papers were identified by a manual search of references from key articles. RESULTS： ALPPS induces more hypertrophy of the FLR in less time than portal vein embolization or portal vein ligation. The benefits of ALPPS include rapid hypertrophy 47%-110% of the liver over a median of 6-16.4 days, and 95%-100% com- pletion rate of the second stage of ALPPS. The main criticisms of ALPPS are centered on its high morbidity and mortality rates. Morbidity rates after ALPPS have been reported to be 15.3%-100%, with ≥ the Clavien-Dindo grade III morbidity of 13.6%-44%. Mortality rates have been reported to be 0%-29%. The important questions to ask even if oncologic long-term results are acceptable are： whether the gain in quality and quantity of life can be off balance by the substantial risks of morbidity and mortality, and whether stimulation of rapid liver hypertrophy also accelerates rapid tumor progression and spread. Up till now, the documentations of the ALPPS procedure come mainly from case series, and most of these series include heterogeneous groups of malignancies. The numbers are also too small to separately evaluate survival for different tumor etiologies. CONCLUSIONS： Currently, knowledge on ALPPS is limited, and prospective randomized studies are lacking. From the reported prelimina展开更多
Primary liver cancer is amongst the commonest tumors worldwide,particularly in parts of the developing world,and is increasing in incidence. Over the past three decades,surgical hepatic resection has evolved from a hi...Primary liver cancer is amongst the commonest tumors worldwide,particularly in parts of the developing world,and is increasing in incidence. Over the past three decades,surgical hepatic resection has evolved from a high risk,resource intensive procedure with limited application,to a safe and commonly performed operation with a range of indications. This article reviews the approach to surgical resection for malignancies such as hepatocellular cancer,metastatic liver de-posits and neuroendocrine tumors. Survival data after resection is also reviewed,as well as indications for curative resection.展开更多
Surgical resection of colorectal liver metastases(CRLM) has a well-documented improvement in survival. To benefit from this intervention, proper selection of patients who would be adequate surgical candidates becomes ...Surgical resection of colorectal liver metastases(CRLM) has a well-documented improvement in survival. To benefit from this intervention, proper selection of patients who would be adequate surgical candidates becomes vital. A combination of imaging techniques may be utilized in the detection of the lesions. The criteria for resection are continuously evolving; currently, the requirements that need be met to undergo resection of CRLM are: the anticipation of attaining a negative margin(R0 resection), whilst maintaining an adequate functioning future liver remnant. The timing of hepatectomy in regards to resection of the primary remains controversial; before, after, or simultaneously. This depends mainly on the tumor burden and symptoms from the primary tumor. The role of chemotherapy differs according to the resectability of the liver lesion(s); no evidence of improved survival was shown in patients with resectable disease who received preoperative chemotherapy. Presence of extrahepatic disease in itself is no longer considered a reason to preclude patients from resection of their CRLM, providing limited extra-hepatic disease, although this currently is an area of active investigations. In conclusion, we review the indications, the adequate selection of patients and perioperative factors to be considered for resection of colorectal liver metastasis.展开更多
Fifteen percent to twenty-five percent of patients affected by colorectal cancer presents with liver metastases at diagnosis. In resectable cases, surgery is the only potentially curative treatment and achieves surviv...Fifteen percent to twenty-five percent of patients affected by colorectal cancer presents with liver metastases at diagnosis. In resectable cases, surgery is the only potentially curative treatment and achieves survival rates up to 50% at 5 years. Management is complex, as colorectal resection, liver resection, chemotherapy, and, in locally advanced mid/low rectal tumors, radiotherapy have to be integrated. Modern medical practice usually relies on evidence-based protocols. Levels of evidence for synchronous metastases are poor:published studies include few recent prospective series and several retrospective analyses collecting a limited number of patients across long periods of time. Data are difficult to be generalized and are mainly representative of single centre's experience, biased by local recruitment, indications and surgical technique. In this context, surgeons have to renounce to "evidence-based medicine" and to adopt a sort of "experience-based medicine". Anyway, some suggestions are possible. Simultaneous colorectal and liver resection can be safely performed whenever minor hepatectomies are planned, while a case-by-case evaluation is mandatory in case of more complex procedures. Neoadjuvant chemotherapy is preferentially scheduled for patients with advanced metastatic tumors to assess disease biology and to control lesions. It can be safely performed with primarytumor in situ , even planning simultaneous resection at its end. Locally advanced mid/low rectal tumor represents a further indication to neoadjuvant therapies, even if treatment's schedule is not yet standardized. In summary, several issues have to be solved, but every single HPB centre should define its proper strategy to optimize patient's selection, disease control and safety and completeness of surgery.展开更多
文摘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.
文摘Objective: To analyze the volumetric modifications of the non tumourous part of the liver when liver metastases (LM) decrease under chemotherapy. Methods: Patients were highly selected based on the following criteria: multiple bilateral large colorectal LM, response of LM attaining at least 85% under chemotherapy. The volumes and ratios of the whole liver, of the LM, and mainly of the non tumourous (normal) part of the liver, were measured on CT scan before and after chemotherapy. Results: Only ten (5%) among 198 treated patients were eligible. Nine of them had received intra-arterial chemotherapy. Metastatic involvement was initially 34% before chemotherapy (range: 13% - 75%), and was 5% (range: 1% - 25%) after chemotherapy. The whole liver volume decreased by 41% (range: 23% - 68%) after chemotherapy. The non metastatic liver (volume and ratio) decreased after chemotherapy in 6 patients and increased in 4 patients. The volume and ratio increased in the 4 patients whose disease initially exhibited the highest metastatic involvement (p = 0.01). Conclusion: The volume of the non metastatic part of the liver varied slightly under standard chemotherapy. Intra-arterial chemotherapy induces dramatic responses, but also liver injury which impairs liver regeneration. However increasing volumes were observed when initial tumour involvement was major.
文摘肝脏是结直肠癌血行转移最主要的靶器官,结直肠癌肝转移（colorectal cancer liver metastases）是结直肠癌治疗的重点和难点之一。约15%~25%结直肠癌病人在确诊时即合并有肝转移,另有15%~25%的病人将在行结直肠癌原发灶根治术后发生肝转移,其中绝大多数（80%~90%）的肝转移灶无法获得根治性切除。
文摘第一部分诊疗指南 肝脏是结直肠癌血行转移最主要的靶器官，结直肠癌肝转移（colorectal cancer liver metastases）是结直肠癌治疗的重点和难点之一。15％-25％的结直肠癌病人在确诊时即合并肝转移，另有15％-25％的病人将在结直肠癌根治术后发生肝转移，其中绝大多数（80％-90％）的肝转移灶初始无法获得根治性切除。
文摘BACKGROUND： Associating liver partition and portal vein ligation for staged hepatectomy （ALPPS） has recently been developed to induce rapid liver hypertrophy and reduce posthepatectomy liver failure in patients with insufficient future liver remnant （FLR）. ALPPS is still considered to be in an early developmental phase because surgical indications and techniques have not been standardized. This article aimed to review the current role and future developments of ALPPS. DATA SOURCES： Studies were identified by searching MED- LINE and PubMed for articles from January 2007 to October 2016 using the keywords ＂associating liver partition and portal vein ligation for staged hepatectomy＂ and ＂ALPPS＂ Addi- tional papers were identified by a manual search of references from key articles. RESULTS： ALPPS induces more hypertrophy of the FLR in less time than portal vein embolization or portal vein ligation. The benefits of ALPPS include rapid hypertrophy 47%-110% of the liver over a median of 6-16.4 days, and 95%-100% com- pletion rate of the second stage of ALPPS. The main criticisms of ALPPS are centered on its high morbidity and mortality rates. Morbidity rates after ALPPS have been reported to be 15.3%-100%, with ≥ the Clavien-Dindo grade III morbidity of 13.6%-44%. Mortality rates have been reported to be 0%-29%. The important questions to ask even if oncologic long-term results are acceptable are： whether the gain in quality and quantity of life can be off balance by the substantial risks of morbidity and mortality, and whether stimulation of rapid liver hypertrophy also accelerates rapid tumor progression and spread. Up till now, the documentations of the ALPPS procedure come mainly from case series, and most of these series include heterogeneous groups of malignancies. The numbers are also too small to separately evaluate survival for different tumor etiologies. CONCLUSIONS： Currently, knowledge on ALPPS is limited, and prospective randomized studies are lacking. From the reported prelimina
基金Supported by NIHR Biomedical Research Centre funding scheme
文摘Primary liver cancer is amongst the commonest tumors worldwide,particularly in parts of the developing world,and is increasing in incidence. Over the past three decades,surgical hepatic resection has evolved from a high risk,resource intensive procedure with limited application,to a safe and commonly performed operation with a range of indications. This article reviews the approach to surgical resection for malignancies such as hepatocellular cancer,metastatic liver de-posits and neuroendocrine tumors. Survival data after resection is also reviewed,as well as indications for curative resection.
文摘Surgical resection of colorectal liver metastases(CRLM) has a well-documented improvement in survival. To benefit from this intervention, proper selection of patients who would be adequate surgical candidates becomes vital. A combination of imaging techniques may be utilized in the detection of the lesions. The criteria for resection are continuously evolving; currently, the requirements that need be met to undergo resection of CRLM are: the anticipation of attaining a negative margin(R0 resection), whilst maintaining an adequate functioning future liver remnant. The timing of hepatectomy in regards to resection of the primary remains controversial; before, after, or simultaneously. This depends mainly on the tumor burden and symptoms from the primary tumor. The role of chemotherapy differs according to the resectability of the liver lesion(s); no evidence of improved survival was shown in patients with resectable disease who received preoperative chemotherapy. Presence of extrahepatic disease in itself is no longer considered a reason to preclude patients from resection of their CRLM, providing limited extra-hepatic disease, although this currently is an area of active investigations. In conclusion, we review the indications, the adequate selection of patients and perioperative factors to be considered for resection of colorectal liver metastasis.
文摘Fifteen percent to twenty-five percent of patients affected by colorectal cancer presents with liver metastases at diagnosis. In resectable cases, surgery is the only potentially curative treatment and achieves survival rates up to 50% at 5 years. Management is complex, as colorectal resection, liver resection, chemotherapy, and, in locally advanced mid/low rectal tumors, radiotherapy have to be integrated. Modern medical practice usually relies on evidence-based protocols. Levels of evidence for synchronous metastases are poor:published studies include few recent prospective series and several retrospective analyses collecting a limited number of patients across long periods of time. Data are difficult to be generalized and are mainly representative of single centre's experience, biased by local recruitment, indications and surgical technique. In this context, surgeons have to renounce to "evidence-based medicine" and to adopt a sort of "experience-based medicine". Anyway, some suggestions are possible. Simultaneous colorectal and liver resection can be safely performed whenever minor hepatectomies are planned, while a case-by-case evaluation is mandatory in case of more complex procedures. Neoadjuvant chemotherapy is preferentially scheduled for patients with advanced metastatic tumors to assess disease biology and to control lesions. It can be safely performed with primarytumor in situ , even planning simultaneous resection at its end. Locally advanced mid/low rectal tumor represents a further indication to neoadjuvant therapies, even if treatment's schedule is not yet standardized. In summary, several issues have to be solved, but every single HPB centre should define its proper strategy to optimize patient's selection, disease control and safety and completeness of surgery.
