Hybrid Partial ALPPS: a Feasible Approach in Case of Right Trisegmentectomy and Macrovascular Invasion

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To the Editor:
We read with great interest the letter published by Li et al1 in Annals of Surgery in January 2016, in which a “hybrid” Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) was proposed.
The Authors reported 2 cases of tumor infiltrating the right liver hilum managed with stage 1 based on an in situ split of the left lateral liver lobe plus a “nontouch” technique of the hilum; postoperative radiological right portal vein (RPV) embolization; and finally stage 2 based on a right trisegmentectomy.
The great benefit of this approach is connected with the opportunity to surgically explore the hilum, thus possibly confirming the preoperative suspect of RPV tumor infiltration. It is in fact clear that the management of an infiltrated hilum may represent a great surgical and oncological challenge.
Starting from these considerations, we here propose a slightly modified approach of this “hybrid ALPPS,” specifically usable in patients with preoperative suspicion of vascular invasion involving RPV and/or inferior cava vein (ICV) requiring a right trisegmentectomy. Both the reported cases were performed in Sapienza University of Rome from August to September 2016.
The first patient was a 50-year-old woman with the diagnosis of a 18-cm-sized intrahepatic cholangiocellular cancer infiltrating the RPV, and with the radiological suspicion of carcinosis and ICV tumor involvement.
The second case was a 67-year-old woman with the diagnosis of right lobe-located multiple colorectal cancer metastases infiltrating right and median hepatic veins, and with a suspicion of ICV infiltration. Both the patients had been initially considered inoperable in other centers.
The surgical strategy we adopted was stage 1 based on minimal tumor manipulation, “no touch” technique of the hilum, partial mobilization of the right lobe (for better evaluating IVC), systematic intraoperatory ultrasounds (for defining patient operability), and partial ALPPS; postoperative radiological RPV embolization; and finally stage 2 finalizing the right trisegmentectomy.
Right portal vein embolization was performed in all the cases on postoperative day (POD) 2.
In the first case, decision to perform an ALPPS derived from the initial low value of future liver remnant (FLR) (segments 2 + 3 = 318 mL), with a FLR/total liver volume (TLV) ratio of 18.5% (normal liver parenchyma = cut-off 25.0%). After partial ALPPS and embolization, an abdominal computed tomography (CT) scan performed on POD 7 reported a FLR of 450 mL, with a FLR/TLV of 26.2% (Fig. 1).
Similarly, in the second case, the initial FLR was insufficient (segment 2 + 3 = 398 mL), with FLR/TLV of 26.0% (postchemotherapy liver = cut-off 30.0%); after RPV embolization, an abdominal CT scan performed on POD 7 resulted in a final FLR of 490 mL, with a FLR/TLV of 32.0%.
In both the cases, carcinosis was not detected during surgery. At pathological specimen, resection margins were free of tumor (R0). Postoperative course was uneventful, with patient's discharge on poststage 2, day 8 and 12, respectively. Three months after surgery, both the patients are alive without recurrences.
In the series reported here, we describe for the first time the “hybrid partial ALPPS” technique. We think this approach can optimize the surgical management of patients with huge tumor involvement of the right lobe with high suspicion of vascular invasion requiring a right trisegmentectomy. The first “minimal” stage of this approach consents to identify potentially resectable patients—thanks to the intraoperative evaluation; systematic use of ultrasounds can be extremely useful in detecting vascular invasion at the level of hilum and ICV. The decision to perform only a partial ALPPS consents to minimize the risks of complications,2 optimizing the management in the outflow of segment 4,3 and consenting to avoid the risk of biliary leaks following the involuntary section of the segment 4 bile duct.
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