Is Partial-ALPPS Safer Than ALPPS? A Single-center Experience
Is Partial-ALPPS Safer Than ALPPS? A Single-center Experience
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DOI：
10.1097/sla.0000000000001087
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发表时间：
2015-04-01
影响因子：
9
通讯作者：
Clavien, Pierre-Alain
中科院分区：
文献类型：
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作者：
Petrowsky, Henrik;Gyoeri, Georg;Clavien, Pierre-Alain
近年来，联合肝分割和门静脉结扎的分期肝切除术（ALPPS）在肝胆外科的临床应用为各种原发性不可切除的肝脏肿瘤患者提供了一种新的、有前途的治疗策略。1，2尽管ALPPS在引发部分肝脏快速肥大方面具有很大的潜力，但主要关注的是手术的安全性。例如，在德国的初始系列中报告的死亡率为12% 2，在随后的多中心分析中为15% 3，在有经验的肝胆中心甚至达到27%。4这些数字促使人们寻求更好的选择标准和/或技术改进，以实现更安全的手术。最近发表的一项对包括202例患者的国际ALPPS登记研究的分析显示，院内死亡率为9%，严重并发症（≥ 3b级）5的发生率为28%。6该队列的风险分析表明，老年患者（> 60岁）和非结直肠肝肿瘤患者的预后较差。6为了更好地了解潜在的机制和相关的危害，我们开发了一种ALPPS实验模型，该模型表明ALPPS的加速再生不仅与肝实质横断和肝脏两部分之间的血液供应中断有关，而且主要是由于导致肝细胞生长增强的“炎症样反应”。[7]这一发现被与肾、肺或脾损伤相关的门静脉结扎对肝再生的类似作用所证实，而不是肝横断。此外，我们在实验模型中观察到，与完全横断相比，部分（75%-80%）横断肝脏引发了未来肝脏残留物（FLR）的相当程度的再生。除了这些新的实验发现，我们已经产生的假设，从我们的早期临床经验，完全横断的实质可能会增加术后肝损伤，例如，通过引起充血的“去门”的一部分，肝脏。根据我们的实验和临床观察，我们开发了一种新策略，于2013年在我们的机构引入，从完全横断切换到明确的部分横断（> 50%的横断表面）。这一想法背后的基本原理是我们的假设，即部分ALPPS更安全，并实现类似的快速肥大。本报告介绍了我们的部分横断经验，标记为部分ALPPS（均缩写为p-ALPPS），与ALPPS相比，观察FLR肥大和术后结局。我们在第1阶段对无胆汁淤积和无胆汁淤积的患者进行了24例ALPPS手术，
The recent introduction of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) into the clinical practice of hepatobiliary surgery has offered a novel and promising treatment strategy for patients with a variety of primarily nonresectable hepatic tumors. 1, 2 Despite the great potential of ALPPS in triggering rapid hypertrophy of parts of the liver, the main concern is the safety of the procedure. For example, the reported mortality in the initial series from Germany was 12% 2 and 15% in a subsequent multicentric analysis, 3 reaching even 27% in experienced hepatobiliary centers. 4 Such figures have triggered the search for better selection criteria and/or technical modification enabling safer surgery. A recently published analysis of the international ALPPS registry including 202 patients revealed an in-hospital mortality rate of 9% and a severe complication (grade≥ 3b) 5 rate of 28%. 6 The risk analysis of this cohort suggested that older patients (> 60 years of age) and those with noncolorectal liver tumors had poorer prognosis. 6 To better understand the underlying mechanisms and associated harms, we have developed an experimental model of ALPPS that showed that accelerated regeneration in ALPPS is not solely related to parenchymal transection and discontinuation of blood supply between the 2 parts of the liver but mostly due to an “inflammatorylike reaction” leading to enhanced hepatocyte growth. 7 This finding was substantiated by a similar effect on liver regeneration for portal vein ligation associated with kidney, lung, or spleen injuries instead of hepatic transection. Also, we observed in the experimental model that partial (75%–80%) transection of the liver triggered a comparable degree of regeneration of the future liver remnant (FLR) when compared with complete transection. Aside with these novel experimental findings, we have generated the hypothesis, from our early clinical experience, that complete transection of the parenchyma may enhance postoperative liver injury, for example, by causing congestion of the “deportalized” part of the liver. On the basis of our experimental and clinical observations, we developed a new strategy, introduced in 2013 at our institution, to switch from complete transection to a well-defined partial transection (> 50% of the transection surface). The rationale behind this idea was our hypothesis that partial ALPPS is safer and achieves similar rapid hypertrophy. This report presents our experience with partial transection, labeled as partial-ALPPS (both abbreviated as p-ALPPS), compared with ALPPS looking at hypertrophy of the FLR and postoperative outcome. We performed 24 ALPPS procedures in noncirrhotic and noncholestatic patients without major extrahepatic surgery at stage 1