Pushing the Envelope in Perihiler Cholangiocellularcarcinoma Surgery: TIPE-ALPPS

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Perihiler cholangiocellularcarcinoma (P-CCC) is a deadly disease with surgery being the only curative option. However, resection for P-CCC is associated with a serious perioperative mortality of 5 to 18% in experienced eastern and western series, even when bile duct resection only cases were included.1 In P-CCC patients with future liver remnant (FLR) <30%, it is advised that hepatectomy can be safely performed only after the FLR is modified.2 Associating Liver Partition and Portal vein ligation for Staged Hepatectomy (ALPPS) procedure has been advocated as a potential solution for achieving rapid FLR hypertrophy but it is considered controversial for this cohort.3 A recent analysis comparing matched patients from 2 experienced western centers with ALPPS Registry data, who underwent resection for P-CCC with and without ALPPS procedure, had 48 versus 28% mortality. The overall survival was 6 months for the ALPPS group compared with 29 months for the matched control group.4 Furthermore, another recent report from the ALPPS registry, identifying a risk score for futile ALPPS procedure identified biliary tumors as significant risk factor with an odds ratio of 3.8. This raises the issue of whether ALPPS is indicated to enter a 2-stage endeavor for patients with P-CCC.5 At this point, before coming to a conclusion of prohibiting ALPPS for P-CCC,6 liver surgeons should consider evolution of this novel procedure.
ALPPS was an important innovation, created enthusiasm among surgeons but has been heavily criticised based on the initially reported high perioperative mortality of 15%.7 However, a recent registry analysis showed that in experienced centers where major issues related to technique, patient selection, and timing have been overcome, perioperative mortality could be reduced to 4%.8 The modifications of several technical difficulties and logistic issues resulted in decreased mortality and morbidity of the procedure. The Mini-ALPPS variant, a hybrid approach combining interventional radiology for portal vein embolization and partial parenchymal division is an important technical modification by minimizing the stress of the first stage.9 In addition, the timing of the 2nd stage of usually 7 to 10 days after the 1st stage when FLR hypertrophy is achieved has been also challenged with functional studies. It has been suggested to wait until patients’ liver function has been normalized, and not taking FLR volumetry as the sole endpoint for decision making for proceeding with 2nd stage. This might be another important point, which also contributed to better outcomes.10
Sakamoto et al have provided a possible alternative, a technical variant of Mini-ALPPS which they name as (Trans ileocecal portal embolization) TIPE-ALPPS. This procedure addresses some of the limitations of the “classical” ALPPS procedure in P-CCC patients with poor liver function. They reported a hybrid approach combining interventional radiology for portal vein embolization and performing partial parenchymal transection for less invasive 1st stage. The authors describe their experience with 3 consecutive patients undergoing major hepatectomy (plus pancreaticoduodenectomy in a case with cystic duct tumor) for P-CCC, 2 right hepatectomies, and 1 left trisectionectomy. One of the important key features of TIPE-ALPPS was the strict avoidance of hepatoduodenal ligament dissection by using a hybrid angiography suite for portal vein embolization through an intraoperative ileocecal vein approach. Even when embolization was not successful, the authors describe being able to percutaneously re-embolize the recanalized portal vein on day 12 which provided adequate hypertrophy of the FLR in the follow-up. The 2nd stages were not straight forward which is reflected by a long mean operative time of 563 minutes (375–674) and an estimated blood loss of 1030 mL (270–1130). There were no bile leakage or posthepatectomy liver failure in all three patients.
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