ALPPS
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Hybrid ALPPS
Dr Jun LI from the University of Hamburg has developed a new approach of ALPPS to treat the tumor infiltration of the right portal vein or biliary bifurcation.
Jun calls the combination of both, parechymal transection in the first stage and portal vein embolization one day later, as "HYPBRID ALPPS".
The important information is not only the technique refinement, but the concept of non-touch technique to treat hepatic malignancy in ALPPS.
He describes this approach in a letter to the Annals of Surgery.
Plaese click on the PubMed link below to access Juns contribution:
Avoid "All-Touch" by Hybrid ALPPS to Achieve Oncological Efficacy.
Li J, Kantas A, Ittrich H, Koops A, Achilles EG, Fischer L, Nashan B.
Ann Surg. 2014 Jul 28. [Epub ahead of print] PubMed PMID: 25072445.
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Hybrid ALPPS
When we analyzed the data from the first 202 cases entered into the ALPPS registry we found that cholangiocarcinoma and gallbladder cancer had the highest perioperative morbidity and mortality with ALPPS. A frequent complication is that the arterial blood supply is already compromised the side to be deportalitzed and the morbidity and mortality may be a result of a larger amount of necrosis in the deportalized lobe than commonly observed with ALPPS. A second porblem is the cumulative amount of surgery adding a hepaticojejunostomy either during the first or the second stage Additionally to that the concept of ligating the portal vein of the contralateral lobe violates the Non-touch technique as has been pointed out by Belghiti in his early letter in response to the Schnitzbauer paper.
Hybrid ALPPS may be the solution for all of these problems as Jun points out in his letter. It is nice to see how the concept of rapid hypertrophy is introduced into liver surgery by modifying the orgininal procedure. ALPPS in its orginal form is like the Zeppelin to civil aviation, it enabled it, but ultimalty proved to diffcult to maneuver and too dangerous.
Ricardo Robles from Murcia is currently analyzing the outcomes of the different modifications of ALPPS in the registy: we will see what comes out of this.
Hybrid ALPPS, as we colled by SEQUENTIAL ALTPS
We think that this method is indicated for tumors invading the hepatic hilum to maintain "non-touch" technique. We performed this technique in December of 2012 for the first time in cholangiocarcinoma invading the hepatic hilum and we performed a right trisectionectomy and inferior vena cava resection replacement it with a goretex graft. The clinical case has been accepted for publication in Cirugía Española (it will be published in December 2014).
Since then we have performed 8 cases in tumors that involved the right portal pedicle or hepatic hilum, associating in 4 patients resection of the inferior vena cava. In the first intervention we perform staging and put the tourniquet on the liver section line (umbilical cissura or Cantle line), without manipulating the hepatic hilum. On the 4th postoperative day we embolized the right portal vein in the 8 cases with success (SEQUENTIAL ALTPS). Before portal vein embolization, we perform a new TC, finding that there is an increase in volume of the left lobe with only occlude intrahepatic collaterals. After PVE, a TC is performed within 7 days, showing a median increase of volume of 96% (greater than ALPPS and ALTPS). One patient died (with resection of vena cava and portal vein) due to complications related to the hepaticojejunostomy. The article have been written (these 8 cases) and will soon be sent to publish.
ALPPS is a good technique but very aggressive for patients with cancers and can spread so much manipulation of the tumor, especially upcoming branches invading the hepatic hilum (Klatskin, cholangiocarcinoma, etc). We also believe that the SEQUENTIAL method (portal vein embolization at 4th day)can be beneficial for the liver function.
Ricardo, you should call it "Hybrid ALTPS"
So, if I understand you right, Roberto, you are describing 8 cases of "Hybrid ALTPS". I believe that this modification works just as well as hybrid ALPPS, but we need to study it in the registry. You have a project running in the registry and I am very interested to see the results here as well.
BTW, The reason why you saw hypertrophy just after banding the liver might very well ahve to do that your right portal vein was compromised already through the tumor as is frequently the case in these patients. You bascially performed a "salvage ALTPS": the liver would have not have grown through the right portal compromise alone but with parenchymal transection it did.
Greetings from Zurich!