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
目的探讨全腹腔镜下前入路经肝后隧道绕肝带结扎和门静脉结扎分期肝切除术(ALTPS)在乙肝肝硬变肝癌患者治疗中的应用价值。方法 2014年9月,笔者所在医院收治1例合并肝硬变的右肝原发性肝癌患者,采用全腹腔镜前入路ALTPS方案:一期手术行...目的探讨全腹腔镜下前入路经肝后隧道绕肝带结扎和门静脉结扎分期肝切除术(ALTPS)在乙肝肝硬变肝癌患者治疗中的应用价值。方法 2014年9月,笔者所在医院收治1例合并肝硬变的右肝原发性肝癌患者,采用全腹腔镜前入路ALTPS方案:一期手术行腹腔镜下门静脉右支结扎,前入路肝后间隙放置绕肝带结扎肝正中裂,不离断肝实质;一期手术10 d后再行全腹腔镜下右半肝切除术。结果术前评估行右半肝切除术后剩余肝脏体积(FLR)为301.48 m L,占标准肝脏体积的29.1%,占体质量的0.49%。一期手术后4 d,FLR为496.45 m L,占标准肝体积的47.9%,占体质量的0.81%,FLR较术前增加64.67%;术后第8天FLR为510.96 m L,占标准肝脏体积的49.3%,占体质量的0.84%,FLR较术前增加69.48%。术后第10天,二期行全腹腔镜右半肝切除术,二期手术后5 d,测残肝体积为704.53 m L。两次手术时间分别为180 min和220 min,出血量分别为50 m L和400 m L。术后恢复良好,术后7 d出院。结论作为联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)的一种更简便、安全、微创及更符合肿瘤学原则的改良,前入路全腹腔镜下ALTPS也能使残肝在短期内快速增生,并且对合并肝硬变的肝癌手术仍然安全可行。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
Alveolar echinococcosis(AE) is a zoonotic disease that is caused by Echinococcus multilocularis that affects liver and a variety of organs and tissues. It differs from other echinococcal disease because it shows tumor...Alveolar echinococcosis(AE) is a zoonotic disease that is caused by Echinococcus multilocularis that affects liver and a variety of organs and tissues. It differs from other echinococcal disease because it shows tumor like behavior in the affected organ and tissues. The treatment of choice is concomitant medical therapy and resection with negative margins. Nevertheless, resection with the intent of negative margins(R0) may lead to serious complications such as liver failure. In the present case report, we used Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy(ALPPS) procedure, which was defined in 2012 by Schnitzbauer et al, in a 28-year-old male patient to avoid complications of major liver resection in order to treat alveolar echinococcosis. Until now, we have not encountered any study using ALPPS procedure for the treatment of alveolar echinococcosis. In the present case report we aimed to show that ALPPS procedure can be safely performed for marginnegative resection of primary or recurrent AE that shows a tumor like behavior. It is our opinion that this procedure should be performed in centers that have expertise and sufficient technical capacity to perform liver transplantation and advanced liver surgery.展开更多
AIM: To investigate the effects of glutamine on oxidative/nitrosative stress and the vascular endothelial growth factor (VEGF)-Akt-endothelial nitric oxide synthase (eNOS) signaling pathway in an experimental model of...AIM: To investigate the effects of glutamine on oxidative/nitrosative stress and the vascular endothelial growth factor (VEGF)-Akt-endothelial nitric oxide synthase (eNOS) signaling pathway in an experimental model of portal hypertension induced by partial portal vein ligation (PPVL). METHODS: Portal hypertension was induced by PPVL. The PPVL model consists of a partial obstruction of the portal vein, performed using a 20 G blunt needle as a guide, which is gently removed after the procedure. PPVL model was performed for 14 d beginning treatment with glutamine on the seventh day. On the fifteenth day, the mesenteric vein pressure was checked and the stomach was removed to test immunoreactivity and oxidative stress markers. We evaluated the expression and the immunoreactivity of proteins involved in the VEGF-Akt-eNOS pathway by Western blotting and immunohistochemical analysis. Oxidative stress was measured by quantification of the cytosolic concentration of thiobarbituric acid reactive substances (TBARS) as well as the levels of total glutathione (GSH), superoxide dismutase (SOD) activity, nitric oxide (NO) production and nitrotyrosine immunoreactivity. RESULTS: All data are presented as the mean ± SE. The production of TBARS and NO was significantly increased in PPVL animals. A reduction of SOD activity was detected in PPVL + G group. In the immunohistochemical analyses of nitrotyrosine, Akt and eNOS, the PPVL group exhibited significant increases, whereas decreases were observed in the PPVL + G group, but no difference in VEGF was detected between these groups. Western blotting analysis detected increased expression of phosphatidylinositol-3-kinase (PI3K), P-Akt and eNOS in the PPVL group compared with the PPVL + G group, which was not observed for the expression of VEGF when comparing these groups. Glutamine administration markedly alleviated oxidative/nitrosative stress, normalized SOD activity, increased levels of total GSH and blocked NO overproduction as well as the formation of peroxynitrite. CONCLUSION:展开更多
目的探讨前入路肝切除联合选择性肝静脉阻断技术在联合肝脏分隔和门静脉结扎的二步肝切除(ALPPS)治疗肝右叶巨块型肝癌中的应用价值。方法收集广西医科大学第一附属医院肝胆外科2017年1月至2017年9月期间采用前入路肝切除联合选择性肝...目的探讨前入路肝切除联合选择性肝静脉阻断技术在联合肝脏分隔和门静脉结扎的二步肝切除(ALPPS)治疗肝右叶巨块型肝癌中的应用价值。方法收集广西医科大学第一附属医院肝胆外科2017年1月至2017年9月期间采用前入路肝切除联合选择性肝静脉阻断技术行ALPPS治疗的9例肝右叶巨块型肝癌患者的临床资料。结果6例患者完整接受ALPPS手术,3例患者因第一期手术后剩余肝脏体积增长不达标而未行第二期手术。ALPPS第一期术后剩余肝脏平均增长体积为139.1 cm^3(46.4~291.6 cm^3),剩余肝脏体积平均增长率为37.8%(15.1%~76.2%),术中平均出血量为356 m L(200~600 m L)。ALPPS第二期手术行右半肝切除4例,扩大右半肝切除2例;术中平均出血量为617 m L(300~1 400 m L)。无胆汁漏及肝功能衰竭并发症发生,无围手术期死亡病例。结论本组有限病例的初步研究结果提示,前入路手术方法联合选择性肝静脉阻断在ALPPS治疗右肝巨块型肝癌中应用是安全、有效的,更符合肿瘤外科的"无瘤"原则,能减少术中出血、胆汁漏等并发症,但其针对合并乙肝后肝硬变肝细胞癌患者的长期治疗效果还需要进一步的病例积累。展开更多
AIM To report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy(ALPPS), after failure of previous portal embolization. We also performed a literature revi...AIM To report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy(ALPPS), after failure of previous portal embolization. We also performed a literature review.METHODS Between January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization(PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps(ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened duringthe interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification.RESULTS From January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc(221-380), 450 cc(372-506), and 660 cc(575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4%(0.3-0.5), 0.6%(0.5-0.8), and 1%(0.8-1.2). Median volume growth of FLR was 69%(18-92) after PVE, and 45%(36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc(254-513), leading to an increase of +149%(68-199). After ALPPS-2, 4 patients had stage Ⅰ-Ⅱ complications. Three patients had more severe complications(one stage Ⅲ, one stage Ⅳ and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure.CONCLUSION Rescue ALPPS m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.
文摘目的探讨全腹腔镜下前入路经肝后隧道绕肝带结扎和门静脉结扎分期肝切除术(ALTPS)在乙肝肝硬变肝癌患者治疗中的应用价值。方法 2014年9月,笔者所在医院收治1例合并肝硬变的右肝原发性肝癌患者,采用全腹腔镜前入路ALTPS方案:一期手术行腹腔镜下门静脉右支结扎,前入路肝后间隙放置绕肝带结扎肝正中裂,不离断肝实质;一期手术10 d后再行全腹腔镜下右半肝切除术。结果术前评估行右半肝切除术后剩余肝脏体积(FLR)为301.48 m L,占标准肝脏体积的29.1%,占体质量的0.49%。一期手术后4 d,FLR为496.45 m L,占标准肝体积的47.9%,占体质量的0.81%,FLR较术前增加64.67%;术后第8天FLR为510.96 m L,占标准肝脏体积的49.3%,占体质量的0.84%,FLR较术前增加69.48%。术后第10天,二期行全腹腔镜右半肝切除术,二期手术后5 d,测残肝体积为704.53 m L。两次手术时间分别为180 min和220 min,出血量分别为50 m L和400 m L。术后恢复良好,术后7 d出院。结论作为联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)的一种更简便、安全、微创及更符合肿瘤学原则的改良,前入路全腹腔镜下ALTPS也能使残肝在短期内快速增生,并且对合并肝硬变的肝癌手术仍然安全可行。
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
文摘Alveolar echinococcosis(AE) is a zoonotic disease that is caused by Echinococcus multilocularis that affects liver and a variety of organs and tissues. It differs from other echinococcal disease because it shows tumor like behavior in the affected organ and tissues. The treatment of choice is concomitant medical therapy and resection with negative margins. Nevertheless, resection with the intent of negative margins(R0) may lead to serious complications such as liver failure. In the present case report, we used Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy(ALPPS) procedure, which was defined in 2012 by Schnitzbauer et al, in a 28-year-old male patient to avoid complications of major liver resection in order to treat alveolar echinococcosis. Until now, we have not encountered any study using ALPPS procedure for the treatment of alveolar echinococcosis. In the present case report we aimed to show that ALPPS procedure can be safely performed for marginnegative resection of primary or recurrent AE that shows a tumor like behavior. It is our opinion that this procedure should be performed in centers that have expertise and sufficient technical capacity to perform liver transplantation and advanced liver surgery.
基金Supported by Hospital de Clínicas de Porto Alegre, FIPE 07284 e 09195, CNPq
文摘AIM: To investigate the effects of glutamine on oxidative/nitrosative stress and the vascular endothelial growth factor (VEGF)-Akt-endothelial nitric oxide synthase (eNOS) signaling pathway in an experimental model of portal hypertension induced by partial portal vein ligation (PPVL). METHODS: Portal hypertension was induced by PPVL. The PPVL model consists of a partial obstruction of the portal vein, performed using a 20 G blunt needle as a guide, which is gently removed after the procedure. PPVL model was performed for 14 d beginning treatment with glutamine on the seventh day. On the fifteenth day, the mesenteric vein pressure was checked and the stomach was removed to test immunoreactivity and oxidative stress markers. We evaluated the expression and the immunoreactivity of proteins involved in the VEGF-Akt-eNOS pathway by Western blotting and immunohistochemical analysis. Oxidative stress was measured by quantification of the cytosolic concentration of thiobarbituric acid reactive substances (TBARS) as well as the levels of total glutathione (GSH), superoxide dismutase (SOD) activity, nitric oxide (NO) production and nitrotyrosine immunoreactivity. RESULTS: All data are presented as the mean ± SE. The production of TBARS and NO was significantly increased in PPVL animals. A reduction of SOD activity was detected in PPVL + G group. In the immunohistochemical analyses of nitrotyrosine, Akt and eNOS, the PPVL group exhibited significant increases, whereas decreases were observed in the PPVL + G group, but no difference in VEGF was detected between these groups. Western blotting analysis detected increased expression of phosphatidylinositol-3-kinase (PI3K), P-Akt and eNOS in the PPVL group compared with the PPVL + G group, which was not observed for the expression of VEGF when comparing these groups. Glutamine administration markedly alleviated oxidative/nitrosative stress, normalized SOD activity, increased levels of total GSH and blocked NO overproduction as well as the formation of peroxynitrite. CONCLUSION:
文摘目的探讨前入路肝切除联合选择性肝静脉阻断技术在联合肝脏分隔和门静脉结扎的二步肝切除(ALPPS)治疗肝右叶巨块型肝癌中的应用价值。方法收集广西医科大学第一附属医院肝胆外科2017年1月至2017年9月期间采用前入路肝切除联合选择性肝静脉阻断技术行ALPPS治疗的9例肝右叶巨块型肝癌患者的临床资料。结果6例患者完整接受ALPPS手术,3例患者因第一期手术后剩余肝脏体积增长不达标而未行第二期手术。ALPPS第一期术后剩余肝脏平均增长体积为139.1 cm^3(46.4~291.6 cm^3),剩余肝脏体积平均增长率为37.8%(15.1%~76.2%),术中平均出血量为356 m L(200~600 m L)。ALPPS第二期手术行右半肝切除4例,扩大右半肝切除2例;术中平均出血量为617 m L(300~1 400 m L)。无胆汁漏及肝功能衰竭并发症发生,无围手术期死亡病例。结论本组有限病例的初步研究结果提示,前入路手术方法联合选择性肝静脉阻断在ALPPS治疗右肝巨块型肝癌中应用是安全、有效的,更符合肿瘤外科的"无瘤"原则,能减少术中出血、胆汁漏等并发症,但其针对合并乙肝后肝硬变肝细胞癌患者的长期治疗效果还需要进一步的病例积累。
文摘AIM To report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy(ALPPS), after failure of previous portal embolization. We also performed a literature review.METHODS Between January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization(PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps(ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened duringthe interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification.RESULTS From January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc(221-380), 450 cc(372-506), and 660 cc(575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4%(0.3-0.5), 0.6%(0.5-0.8), and 1%(0.8-1.2). Median volume growth of FLR was 69%(18-92) after PVE, and 45%(36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc(254-513), leading to an increase of +149%(68-199). After ALPPS-2, 4 patients had stage Ⅰ-Ⅱ complications. Three patients had more severe complications(one stage Ⅲ, one stage Ⅳ and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure.CONCLUSION Rescue ALPPS m
