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5 Management of Patients with Bilateral Multifocal … 63
the patency of the left lateral segment portal vein branches and at the same time to
make sure of the devascularisation of collaterals to the right portal vein. At the end
of the procedure, the catheter is removed from the inferior mesenteric vein, which
can be ligated or repaired whenever possible. As an alternative, the ileocolic vein or
any other dilated splanchnic vein could be cannulated for PVE.
Volumetry is usually performed 6 days after the first stage and assessment before
completion of stage 2 is performed by calculation of sFLR, in conjunction with
99m
Tc-mebrofenin hepatic scintigraphy, which helps to confirm a simultaneous
increase of liver function in the remnant liver.
When future liver remnant volume and function as well as patient conditions are
considered adequate to proceed to second stage, the second surgery can be
scheduled.
In the second stage, fewer adhesions are encountered between the parenchymal
resection surfaces and access to hepatic pedicle is facilitated by lesser hilar
inflammation adherences. Parenchymal splitting is completed following the previous transection line and the right hepatic vein is dissected and divided by a vascular
stapler, finally completing the hepatectomy. At the end of the operation, a
hydraulic test is performed through cannulation of the cystic duct to rule out any
bile leaks. If there are any doubts on the indemnity of the remnant biliary system, a
cholangiography can be performed.
Clinical Pearls
• depth of liver transection should not exceed 3–5 cm, to avoid injury of the
middle hepatic vein and biliary branches of segment 4
• the hepatic pedicle is not dissected at all and should remain untouched
during the entire procedure
• PVE is approached through dissection and cannulation of the inferior
mesenteric vein with a 5 Fr introducer.
Outcome
The patient in this case presented a preoperative non-tumoral volume of the left
lateral section (segments 2–3) plus the caudate lobe (segment 1) of 294 cc, representing 26% of the standardized total liver volume. During the first stage, IOUS
confirmed the presence of one lesion in segment 7, infiltrating the right hepatic vein,
and another one in segment 8, in filtrating the middle hepatic vein. Therefore, a right
trisectionectomy by means of ALPPS due to the insufficient FLR was indicated.
Partial parenchymal transection along the falciform ligament followed by
64 M. Serenari et al.
Fig. 5.2 “Mini-ALPPS” approach: a partial parenchymal transection during first stage. b Isolation
of inferior mesenteric vein for its cannulation. c Intraoperative portal vein embolization.
d Completion of hepatectomy during second stage
embolization of the right portal vein including segment 4, was performed (Fig. 5.2).
Two other lesions were found in the left lateral section, which were resected to
clean the remnant liver. A plastic sheet was left in the abdomen to cover the
surfaces of resection. After 7 days, a first CT volumetry was performed and showed
a sFLR of 33%. Although the good volumetric hypertrophy, the function of the
remnant liver measured by means of
99m
Tc-mebrofenin scintigraphy was not
considered enough to proceed to stage 2. Thereby, hepatobiliary scintigraphy and
CT volumetry were repeated on POD 14, this time showing a 38% of sFLR and a
satisfying remnant liver function (Fig. 5.3). No major complications or
post-hepatectomy liver failure occurred until this point. Completion of right trisectionectomy was finally performed on POD 16 and the patient was discharged 5
days after, without any compl ications. Histological analysis of the specimen confirmed the preoperative diagnosis and tumor-free (R0) resection margins. The
patient received adjuvant chemotherapy with FOLFOX, and 6 months after surgery
is still alive and free of disease.
The above-described technique allows adequate hypertrophy as seen in ALPPS
but with a less aggressive procedure in the first stage. PPT has already been shown
to trigger a similar rate of liver hypertrophy compared to complete transection [51].
Furthermore, risk of bile leak and/or ischemia of segment 4, secondary to incidental
transection of small bile duct and arteries, can be avoided. Association of PPT with
intraoperative PVE results in a less eventful recovery before the second stage, the
5 Management of Patients with Bilateral Multifocal … 65
Fig. 5.3 a SPECT/CT image fusion with 99mTc-mebrofenin, and b three-dimensional CT liver
volumetry of segments 1-2-3, representing the 38% of standardized future liver remnant performed
on postoperative day 14
latter simpli fied by avoiding hepatic hilum dissection and liver manipulation in
stage 1.
In our experi ence, 22 patients were submitted to ALPPS surgery between June
2011 and March 2016 for bilateral colorectal liver metastases (Table 5.1). There
were 14 males and eight females. Liver metastases were synchronous in 20 of 22
cases (90.9%) and metachronous in two patients (9.1%). In seven patients with
synchronous metastases, simultaneous colorectal resection was performed. Major
complications (Dindo-Clavien 3a) occurred in 18.2% and no mortality within
90 days was observed. Free of tumor (R0) margins of resection were obtained in 19
of 22 patients (86.4%). When looking at “mini-ALPPS” series for bilateral colorectal liver metastases (four patients), only one wound infection was encountered
as a surgical complication. Median liver hypertrophy was 47% (range 26–79%)
with a median interval between the first stage and the last volumetric evaluation
before the second stage of 11 days (range 6–16 days). Overall survival at 1, 3, and
5 years was 80.4, 70.4, and 43.2%, respectively.
When comparing outcome following ALPPS to other available treatments for
bilateral CRLM, it must be kept in mind that patients treated with ALPPS represent
a subgroup that cannot be compared to conventional one-stage hepatectomy or
patients submitted to preoperative PVE with monolobar disease. These results have
to be compared to chemotherapy alone and at best to conventional two-stage
hepatectomy (TSH) for bilobar disease with FLR hypertrophy obtained by means of
interstage PVO. A case-ma tch analysis of patients submitted to ALPPS (multicenter) versus TSH (single center) demonstrated significantly higher morbidity
(41.7%) after stage 2 in the ALPPS group, although complications in the TSH
group was fairly lower (17.6%) than in other series [52]. The International Registry
[44] reported a major morbidity of 29% for patients submitted to ALPPS for
CRLM; that is comparable to TSH, ranging from 20% [36] to 59% [53]. Further-
66 M. Serenari et al.
Table 5.1 Descriptive of all patients submitted to ALPPS for bilateral colorectal liver metastases
at Hospital Italiano between 2011 and 2016
Variable n =22
Age, median (range), years 57 (29–81)
Sex, male/female 14/8
Charlson index, median (range), number 7 (6–10)
BMI, median (range), kg/m
2
Preoperative chemotherapy, number (%)
Oxaliplatin-based
Irinotecan-based
Biologic agent
24.4 (16.9–31.2)
21 (95.5)
18 (81.8)
7 (31.8)
12 (54.5)
Cycles of chemotherapy, median (range), number 7 (2–15)
Synchronous/metachronous, number 20/2
Number of lesions on imaging, median (range), number 5 (2–33)
Maximal diameter of the largest lesion, median (range), mm 57.5 (20–160)
sFLR prior to stage 1, median (range), % 25.4 (6.7–30.6)
FLR/BW prior to stage 1, median (range), % 0.55 (0.14–0.69)
sFLR prior to stage 2, median (range), % 44.4 (25.8–68)
FLR/BW prior to stage 2, median (range), % 0.94 (0.54–1.53)
FLR increase, median (range), % 106 (26–286)
KGR, median (range), %/day 15.1 (0.8–28.3)
Time interval, median (range), days 11 (6–16)
Feasibility of stage 2, number (%) 22 (100)
Simultaneous colorectal resection, number (%)
Left hemicolectomy
Anterior rectal resection
Transverse colectomy
Type of liver resection, number (%)
Right hepatectomy
Right trisectionectomy
7 (31.8)
4 (57.1)
2 (28.6)
1 (14.3)
8 (36.4)
13 (59.1)
1 (4.5)
Left trisectionectomy
Partial parenchymal transection, number (%) 17 (77.3)
PPT + PVE (mini-ALPPS), number (%) 4 (18.2)
Major morbidity after stage 1, number (%) 5 (22.7)
Major morbidity after stage 2, number (%) 4 (18.2)
Hospital stay, median (range), days 19 (9–49)
90-day mortality, number (%) 0
Resection margins, number (%)
R0
19 (86.4)
3 (14.6)
R1
sFLR standardized future liver remnant; BW body weight; KGR kynetic growth rate; PPT partial
parenchymal transection; PVE portal vein embolization; ALPPS
associated liver partition and
portal vein ligation
5 Management of Patients with Bilateral Multifocal … 67
more, a 90-day mortality of 5% after ALPPS seems acceptable when compared to
TSH, for which mortality is reported up to 7% [53].
Although only a short-term follow-up is yet available from the last ALPPS
registry report [44], the overall survival (OS) of 59 and 41% and the disease-free
survival (DFS) of 88 and 74% at 1 and 2 years, respectively, compare favorably
with that provided in the few existing international series of two-stage hepatectomies [35]. The most relevant aspect is that survival in ALPPS takes into consideration patients in whom PVE or PVL have failed (“salvage ALPPS”) and
patients who theoretically would have dropped out between stages due to progression of disease in conventional TSH.
Conclusion
ALPPS is not intended to supplant conventional two-stage hepatectomies, but rather
to expand the armamentarium for hepatic resection, and to date, represents the only
chance of cure in patients in whom PVO have failed (salvage ALPPS) or with very
small FLR. Randomized controlled trials comparing ALPPS versus TSH are currently underway and at present any comparison between these two surgical strategies
can only be suggestive, not definitive. Mini-ALPPS represents a further refinement
of classic ALPPS technique and may be useful to reduce the clinical impact of stage
1 before completion of stage 2 [45, 54], obtaining a comparable degree of hypertrophy with a lower rate of complications. An additional oncologic advantage, due to
avoiding hepatic hilum dissection and liver manipulization, is not to be underestimated. Further studies are needed to validate the findings of this original report.
Overall
• ALPPS represents the only chance of cure in patients in whom PVO have
failed (salvage ALPPS) or with very small FLR
• Mini-ALPPS represents a further refinement of classic ALPPS technique
to reduce the clinical impact of stage 1 before completion of stage 2
• ALPPS survival includes patients in whom PVE or PVL have failed and
patients who theoretically would have dropped out between stages due to
progression of disease in conventional TSH
• Randomized controlled tri als comparing ALPPS versus TSH for colorectal liver metastases are currently underway.
68 M. Serenari et al.
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Management of Low Rectal Cancer with Synchronous Liver Metastases
Robert Gandy and Charbel Sandroussi
Introduction
One-quarter of patients with rectal adenocarcinoma have stage IV disease at presentation, and over two-thirds of patients have metastases limited to the liver.
Unresectable liver colorectal liver metastases (CRLM) are associated with only
30% 1-year survival, and long-term survival is worse for patients presenting with
synchronous disease [1].
Successful completion of treatmen t to all sites of disease is the only chance of
cure and is associated with 5-year survival of 55% [2, 3]. Indeed 5-year survival
rates of 67% [4] have been achieved with the addition of neoadjuvant systemic
therapy to control micrometastatic disease and select biologically favorable disease
[5, 6].
Uncertainty remains regarding the optimal sequencing of therapy, the applicability of synchronous resections and the role of pelvic radiotherapy in stage IV
rectal adenocarcinoma [7–11]. The overall goal of treatment is surgical resection of
disease and minimizing delay in systemic treatment.
6
Case Presentation 1
A 65-year-old man with a background of chronic obstructive pulmonary disease
and type 2 diabetes presented with diarrhea and 10 g of unwanted weight loss over
2 months. Colonoscopy revealed an ob structing low rectal tumor. MRI of the
R. Gandy C. Sandroussi (&)
Department of Hepatobiliary and Upper Gastrointestinal Surgery,
Institute of Academic Surgery, Royal Prince Alfred Hospital,
Missenden Road, Camperdown, NSW 2050, Australia
e-mail: Charbel.Sandroussi@gmail.com
© Springer International Publishing AG 2017
T.M. Pawlik et al. (eds.), Case-Based Lessons in the Management of Complex
Hepato-Pancreato-Biliary Surgery, DOI 10.1007/978-3-319-50868-9_6
73