Partial TIPE ALPPS for Perihilar Cancer

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Two-stage hepatectomy combined with in-situ splitting of the liver and concomitant portal ligation during the first stage could facilitate more rapid hypertrophy of the future liver remnant (FLR) than with conventional portal vein embolization (PVE).1,2 This innovative hepatectomy, named Associating Liver Partition and Portal vein embolization for Staged hepatectomy (ALPPS),2 has been associated with a 60% to 80% increase in the original FLR volume over 7 to 10 days, but with 80% morbidity and 9 to 12% mortality.2,3 ALPPS has been indicated in patients with colorectal liver metastasis in 70%, followed by hepatocellular carcinoma in 8% and perihilar cholangiocarcinoma in 5%.3 However, perihilar cancer requiring major hepatectomy and biliary resection was reported a relative contraindication to ALPPS, because of extremely high morbidity and mortality rates.4 The 90-day mortality of biliary tumors, perihilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, and gallbladder cancer were 27%, 13%, and 33%, respectively in the international ALPPS registry.3 An Italian multicenter study reported 40% mortality (10% and 30% during the first and second stages, respectively) in 20 patients with cholangiocarcinoma.5 In this context, we have developed a modified procedure, Associating Liver Partial partition and Trans-Ileocecal Portal vein embolization for Staged hepatectomy, and demonstrated successful results in the first 5 patients.6 The concept of this modified procedure is to reduce the invasiveness of the first-stage hepatectomy partially partitioning the liver along the Rex-Cantlie's line instead of total transection of segment 4 beside the falciform ligament, and embolizing the right portal vein via transileocecal venous approach (TIPE, transileocecal portal vein embolization) instead of ligation. This strategy can be named partial TIPE ALPPS according to the terminology on ALPPS,7 which was almost coincide with that of mini-ALPPS procedure.8 The excellent safety outcomes of partial TIPE ALPPS in our initial series have led us to expand its indication to perihilar cancer, a current relative contraindication to ALPPS.
Between December 2015 and January 2017, 10 patients underwent major hepatectomy with biliary resection for perihilar cancer with (n = 2) or without (n = 8) pancreaticoduodenectomy (PD). Of these, 3 patients (2 men and 1 women; median age 67 years; range 61–78) underwent partial TIPE ALPPS for perihilar cancer, that is, intrahepatic cholangiocarcinoma involving the hepatic hilum in the first, perihilar cholangiocarcinoma in the second, and cystic duct cancer in the third, and the data of the first patient were included in our previous report.6 Right hemihepatectomy (RH) with biliary reconstruction, left trisectionectomy, and RH and PD were scheduled in these patients (Table 1). The original FLR was 26.2% (24.1%–29.8%) and preoperative indocyanine green retention rate at 15 minutes value was 11.3% (6.5%–14.1%). Suppose the increase in FLR is 10%,9,10 FLR after conventional PVE in these 3 patients would not meet our criterion of 40% total liver volume.11 Therefore, we decided to apply partial TIPE ALPPS in them. Two patients developed obstructive jaundice and required preoperative endoscopic biliary drainage. The first stage of partial TIPE ALPPS was performed in a hybrid-angiography room, where clear digital subtraction images could be obtained during TIPE. No dissemination, liver metastases, or para-aortic nodal metastasis was found. Partial partition of the liver was performed along the main portal fissure in 2 patients and right portal fissure in 1 patient until we exposed the wall of the middle hepatic vein and right hepatic vein, respectively. The transected area was 43.5% (41.4%–48.2%) of the estimated total transection area, calculated by integration of the transection line on computed tomography scan on day 7 after the first stage using synapse Vincent (Fujifilm Co Ltd, Japan) (Fig. 1).
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