Associating Liver Partition and Portal vein ligation for Staged hepatectomy after pre‐operative chemotherapy

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Colorectal cancer is one of the most common malignancies in the western world. Approximately half of the patients with colorectal cancer develop liver metastases, which is the major cause of death in these patients. Resection of colorectal liver metastasis (CRLM) still remains the only curative treatment and shows the best long‐term outcome.1
However, in order to achieve a complete resection of CRLM, extended liver resection is often necessary and only 20% of patients can be considered resectable.2 One of the major limitations is the size and function of the future liver remnant (FLR). For primary resectability, the FLR should be at least 20% of the total liver volume in patients without significant liver disease or liver damage.3 Since neoadjuvant chemotherapy became the standard therapy in locally advanced colorectal cancer, many patients presenting with CRLM already received chemotherapy. Chemotherapy‐induced liver injury is associated with post‐operative hepatic insufficiency and mortality after hepatic resection. Therefore, the FLR should be at least 30% in patients receiving hepatotoxic chemotherapy.5
Patients who initially present as non‐resectable usually are treated with chemotherapy in order to downsize the CRLM and convert the disease into a situation that is amenable for surgical treatment. Nevertheless, still 50% of patients remain unresectable.6 However, patients who become resectable after downsizing show promising survival rates of 52–100% at 3 years and 33–43% at 5 years, respectively, compared with 5–10% at 5 years with chemotherapy alone.2
In cases where an insufficient FLR is of major concern – especially following pre‐operative chemotherapy – strategies like portal vein embolization (PVE) and portal vein ligation (PVL) have been developed to increase the FLR and hence prevent small‐for‐size syndrome.7 Recently, the new two‐stage liver resection combining in situ liver transection with PVL, also known as ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy), has been described as a promising approach to increase the resectability of marginally resectable or locally unresectable liver tumours due to faster and more pronounced liver hypertrophy and hence a higher rate of successful resections.8
Altogether, data regarding the use of ALPPS is still highly limited. The presented case series focused on the application of ALPPS in patients with advanced CRLM and extensive pre‐operative chemotherapy, with the aim to analyse whether the latter still allows for sufficient hypertrophy of the FLR following step 1 of ALPPS.
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