ALPPS Offers a Better Chance of Complete Resection in Patients with Primarily Unresectable Liver Tumors Compared with Conventional-Staged Hepatectomies: Results of a Multicenter Analysis
ALPPS Offers a Better Chance of Complete Resection in Patients with Primarily Unresectable Liver Tumors Compared with Conventional-Staged Hepatectomies: Results of a Multicenter Analysis
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DOI：
10.1007/s00268-014-2513-3
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发表时间：
2014-06-01
影响因子：
2.6
通讯作者：
Clavien, Pierre-Alain
中科院分区：
文献类型：
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作者：
Schadde, Erik;Ardiles, Victoria;Clavien, Pierre-Alain
采用门静脉结扎术(PVL)或栓塞术(PVE)，4-8周后切除肝脏，以增加未来残肝(FLR)的大小。分期肝切除联合肝分割门静脉结扎术(ALPPS)联合PVL加全肝实质横断术，术后1~2周内行肝切除。ALPPS最近已被引入，但仍存在争议。我们比较了ALPPS与PVE或PVL在完全切除肿瘤方面的能力。对2003至2012年间在四个大容量HPB中心使用PVL或PVE进行ALPPS或传统分期肝切除术的所有患者进行了回顾。研究对象包括原发性肝肿瘤和肝转移瘤患者。主要终点是肿瘤完全切除。次要终点包括90天死亡率、并发症、FLR增加、切除时间和肿瘤复发。48例ALPPS患者与83例传统分期肝切除术患者进行了比较。83%(40/48例)的ALPPS患者获得完全切除，而PVE/PVL组为66%(55/83例)(优势比3.34，p=0.027)。ALPPS组和PVE/PVL组的90天死亡率分别为15%和6%(p=0.2)。ALPPS的外推生长速度(34.8cc/天；四分位数范围(IQR)26-49)是PVE/PVL(3cc/天；IQR2-6；p=0.001)的11倍。ALPPS组和PVE/PVL组1年肿瘤复发率分别为54%和52%(p=0.7)。这项研究提供了证据，ALPPS为主要不能切除的肝肿瘤患者提供了更好的完全切除机会，但代价是高死亡率。这项技术前景看好，但目前不应在研究和登记之外使用。
Portal vein occlusion to increase the size of the future liver remnant (FLR) is well established, using portal vein ligation (PVL) or embolization (PVE) followed by resection 4-8 weeks later. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) combines PVL and complete parenchymal transection, followed by hepatectomy within 1-2 weeks. ALPPS has been recently introduced but remains controversial. We compare the ability of ALPPS versus PVE or PVL for complete tumor resection.A retrospective review of all patients undergoing ALPPS or conventional staged hepatectomies using PVL or PVE at four high-volume HPB centres between 2003 and 2012 was performed. Patients with primary liver tumors and liver metastases were included. Primary endpoint was complete tumor resection. Secondary endpoints include 90-day mortality, complications, FLR increase, time to resection, and tumor recurrence.Forty-eight patients with ALPPS were compared with 83 patients with conventional-staged hepatectomies. Eighty-three percent (40/48 patients) of ALPPS patients achieved complete resection compared with 66 % (55/83 patients) in PVE/PVL (odds ratio 3.34, p = 0.027). Ninety-day mortality in ALPPS and PVE/PVL was 15 and 6 %, respectively (p = 0.2). Extrapolated growth rate was 11 times higher in ALPPS (34.8 cc/day; interquartile range (IQR) 26-49) compared with PVE/PVL (3 cc/day; IQR2-6; p = 0.001). Tumor recurrence at 1 year was 54 versus 52 % for ALPPS and PVE/PVL, respectively (p = 0.7).This study provides evidence that ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors at the cost of a high mortality. The technique is promising but should currently not be used outside of studies and registries.