Discussion

2
8. Ribero D, Abdalla EK, Madoff DC, et al. Portal vein emboliza- tion before major hepatectomy and its effects on regeneration, resectability and outcome. Br J Surg 2007;94:1386e1394. 9. Shindoh J, Truty MJ, Aloia TA, et al. Kinetic growth rate after portal vein embolization predicts posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant. J Am Coll Surg 2013;216:201e209. 10. Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg 2012; 255:405e414. 11. Knoefel WT, Gabor I, Rehders A, et al. In situ liver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection. Br J Surg 2013;100: 388e394. 12. Dokmak S, Belghiti J. Which limits to the “ALPPS” approach? Ann Surg 2012;256:e6; author reply e16e17. 13. Li J, Girotti P, Ko ¨nigsrainer I, et al. ALPPS in right trisectio- nectomy: a safe procedure to avoid postoperative liver failure? J Gastrointest Surg 2013 Jan 4 [Epub ahead of print]. 14. Truty MJ, Vauthey JN. Uses and limitations of portal vein embolization for improving perioperative outcomes in hepato- cellular carcinoma. Semin Oncol 2010;37:102e109. 15. Vauthey JN, Abdalla EK, Doherty DA, et al. Body surface area and body weight predict total liver volume in Western adults. Liver Transpl 2002;8:233e240. 16. Abdalla EK, Barnett CC, Doherty D, et al. Extended hepatec- tomy in patients with hepatobiliary malignancies with and without preoperative portal vein embolization. Arch Surg 2002;137:675e680. 17. Vauthey JN, Pawlik TM, Abdalla EK, et al. Is extended hepa- tectomy for hepatobiliary malignancy justified? Ann Surg 2004;239:722e730. 18. Azoulay D, Castaing D, Krissat J, et al. Percutaneous portal vein embolization increases the feasibility and safety of major liver resection for hepatocellular carcinoma in injured liver. Ann Surg 2000;232:665e672. 19. Madoff DC, Hicks ME, Abdalla EK, et al. Portal vein embo- lization with polyvinyl alcohol particles and coils in prepara- tion for major liver resection for hepatobiliary malignancy: safety and effectivenessestudy in 26 patients. Radiology 2003;227:251e260. 20. Kishi Y, Madoff DC, Abdalla EK, et al. Is embolization of segment 4 portal veins before extended right hepatectomy justified? Surgery 2008;144:744e751. 21. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240: 205e213. 22. Koch M, Garden OJ, Padbury R, et al. Bile leakage after hep- atobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011;149:680e688. 23. Mullen JT, Ribero D, Reddy SK, et al. Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatec- tomy. J Am Coll Surg 2007;204:854e862; discussion 862e864. 24. Brouquet A, Abdalla EK, Kopetz S, et al. High survival rate after two-stage resection of advanced colorectal liver metas- tases: response-based selection and complete resection define outcome. J Clin Oncol 2011;29:1083e1090. 25. Aloia TA, Zorzi D, Abdalla EK, Vauthey JN. Two-surgeon technique for hepatic parenchymal transection of the noncir- rhotic liver using saline-linked cautery and ultrasonic dissec- tion. Ann Surg 2005;242:172e177. 26. Sala S, Ardiles V, Ulla M, et al. Our initial experience with ALPPS technique: encouraging results. Updates in Surg 2012;64:167e172. 27. Ishak K, Baptista A, Bianchi L, et al. Histological grading and staging of chronic hepatitis. J Hepatol 1995;22:696e699. Discussion INVITED DISCUSSANT: DR ALAN W HEMMING (San Diego, CA): Liver surgery has had many advances over the last 15 years. One of the most significant of these advances has been recognition of the importance of an adequate future liver remnant (FLR) volume in avoiding major morbidity and mortality after extended liver resection. This, in turn, led to the development of pre- resection methods of interrupting portal flow to the side of the liver planned for resection in order to induce hypertrophy of the FLR. Increasing the FLR has decreased the morbidity and mortality rate in a subset of patients requiring extended hepatectomy and also has expanded the number of patients to whom extended hepa- tectomy can be applied for curative intent. Preoperative right portal vein embolization (PVE), performed percutaneously, or open right portal vein ligation, have been shown to be equivalent methods of inducing FLR hypertrophy. In most major liver centers, percuta- neous PVE is the method of choice because it means 1 open proce- dure rather than 2. The new kid on the block is Associating Liver Partition with Portal vein Ligation for Staged (ALPPS) hepatectomy. Although the procedure itself was initially described several years ago, a recent publication by Drs Schnitzbauer, Clavien, and colleagues, in the Annals of Surgery, has led to increased interest and perhaps scrutiny of the technique. This technique combines open right portal liga- tion and hepatic parenchymal transection along a right trisegmen- tectomy plane, followed 1 to 2 weeks later by completion right trisegmentectomy. Leaving an arterialized right lobe and directing all portal flow to the left lateral segment while also preventing intra- parenchymal crossflow in theory maximizes both the volume increase in the FLR and the rate of volume increase. Today, Drs Shindoh, Vauthey, Aloia, and coauthors, have presented the MD Anderson results with right plus segment 4 PVE plus embolization of segment 4 portal vein branches, and compared them with the results available from the single reported series of 25 patients with ALPPS by Dr Shnitzbauer and colleagues. I would point out that the MD Anderson group has the nation’s largest experi- ence with PVE that includes the segment 4 branches and that it takes an experienced interventional radiology group to avoid compromising flow to the left-lateral segment while occluding the segment 4 branches. Obviously, comparing 2 groups that are not matched is difficult, but it does illustrate some points. Morbidity and mortality appear less with the PVE approach, the increase in FLR is comparable, and patients who develop extrahe- patic disease post-PVE are spared an unnecessary procedure. The Vol. 217, No. 1, July 2013 Shindoh et al Discussion 133

Transcript of Discussion

Vol. 217, No. 1, July 2013 Shindoh et al Discussion 133

8. Ribero D, Abdalla EK, Madoff DC, et al. Portal vein emboliza-tion before major hepatectomy and its effects on regeneration,resectability and outcome. Br J Surg 2007;94:1386e1394.

9. Shindoh J, Truty MJ, Aloia TA, et al. Kinetic growth rate afterportal vein embolization predicts posthepatectomy outcomes:toward zero liver-related mortality in patients with colorectalliver metastases and small future liver remnant. J Am CollSurg 2013;216:201e209.

10. Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portalvein ligation combined with in situ splitting induces rapid leftlateral liver lobe hypertrophy enabling 2-staged extended righthepatic resection in small-for-size settings. Ann Surg 2012;255:405e414.

11. Knoefel WT, Gabor I, Rehders A, et al. In situ liver transectionwith portal vein ligation for rapid growth of the future liverremnant in two-stage liver resection. Br J Surg 2013;100:388e394.

12. Dokmak S, Belghiti J. Which limits to the “ALPPS” approach?Ann Surg 2012;256:e6; author reply e16e17.

13. Li J, Girotti P, Konigsrainer I, et al. ALPPS in right trisectio-nectomy: a safe procedure to avoid postoperative liver failure?J Gastrointest Surg 2013 Jan 4 [Epub ahead of print].

14. Truty MJ, Vauthey JN. Uses and limitations of portal veinembolization for improving perioperative outcomes in hepato-cellular carcinoma. Semin Oncol 2010;37:102e109.

15. Vauthey JN, Abdalla EK, Doherty DA, et al. Body surface areaand body weight predict total liver volume in Western adults.Liver Transpl 2002;8:233e240.

16. Abdalla EK, Barnett CC, Doherty D, et al. Extended hepatec-tomy in patients with hepatobiliary malignancies with andwithout preoperative portal vein embolization. Arch Surg2002;137:675e680.

17. Vauthey JN, Pawlik TM, Abdalla EK, et al. Is extended hepa-tectomy for hepatobiliary malignancy justified? Ann Surg2004;239:722e730.

18. Azoulay D, Castaing D, Krissat J, et al. Percutaneous portalvein embolization increases the feasibility and safety of majorliver resection for hepatocellular carcinoma in injured liver.Ann Surg 2000;232:665e672.

19. Madoff DC, Hicks ME, Abdalla EK, et al. Portal vein embo-lization with polyvinyl alcohol particles and coils in prepara-tion for major liver resection for hepatobiliary malignancy:safety and effectivenessestudy in 26 patients. Radiology2003;227:251e260.

20. Kishi Y, Madoff DC, Abdalla EK, et al. Is embolization ofsegment 4 portal veins before extended right hepatectomyjustified? Surgery 2008;144:744e751.

21. Dindo D, Demartines N, Clavien PA. Classification of surgicalcomplications: a new proposal with evaluation in a cohort of6336 patients and results of a survey. Ann Surg 2004;240:205e213.

22. Koch M, Garden OJ, Padbury R, et al. Bile leakage after hep-atobiliary and pancreatic surgery: a definition and grading ofseverity by the International Study Group of Liver Surgery.Surgery 2011;149:680e688.

23. Mullen JT, Ribero D, Reddy SK, et al. Hepatic insufficiency andmortality in1,059noncirrhotic patients undergoingmajor hepatec-tomy. J Am Coll Surg 2007;204:854e862; discussion 862e864.

24. Brouquet A, Abdalla EK, Kopetz S, et al. High survival rateafter two-stage resection of advanced colorectal liver metas-tases: response-based selection and complete resection defineoutcome. J Clin Oncol 2011;29:1083e1090.

25. Aloia TA, Zorzi D, Abdalla EK, Vauthey JN. Two-surgeontechnique for hepatic parenchymal transection of the noncir-rhotic liver using saline-linked cautery and ultrasonic dissec-tion. Ann Surg 2005;242:172e177.

26. Sala S, Ardiles V, Ulla M, et al. Our initial experience withALPPS technique: encouraging results. Updates in Surg2012;64:167e172.

27. Ishak K, Baptista A, Bianchi L, et al. Histological grading andstaging of chronic hepatitis. J Hepatol 1995;22:696e699.

Discussion

INVITED DISCUSSANT: DR ALAN W HEMMING (San Diego,

CA): Liver surgery has had many advances over the last 15 years.One of the most significant of these advances has been recognitionof the importance of an adequate future liver remnant (FLR)

volume in avoiding major morbidity and mortality after extendedliver resection. This, in turn, led to the development of pre-resection methods of interrupting portal flow to the side of the liver

planned for resection in order to induce hypertrophy of the FLR.Increasing the FLR has decreased the morbidity and mortalityrate in a subset of patients requiring extended hepatectomy andalso has expanded the number of patients to whom extended hepa-

tectomy can be applied for curative intent. Preoperative right portalvein embolization (PVE), performed percutaneously, or open rightportal vein ligation, have been shown to be equivalent methods of

inducing FLR hypertrophy. In most major liver centers, percuta-neous PVE is the method of choice because it means 1 open proce-dure rather than 2.

The new kid on the block is Associating Liver Partition withPortal vein Ligation for Staged (ALPPS) hepatectomy. Althoughthe procedure itself was initially described several years ago, a recent

publication by Drs Schnitzbauer, Clavien, and colleagues, in theAnnals of Surgery, has led to increased interest and perhaps scrutinyof the technique. This technique combines open right portal liga-tion and hepatic parenchymal transection along a right trisegmen-

tectomy plane, followed 1 to 2 weeks later by completion righttrisegmentectomy. Leaving an arterialized right lobe and directingall portal flow to the left lateral segment while also preventing intra-

parenchymal crossflow in theory maximizes both the volumeincrease in the FLR and the rate of volume increase. Today, DrsShindoh, Vauthey, Aloia, and coauthors, have presented the MD

Anderson results with right plus segment 4 PVE plus embolizationof segment 4 portal vein branches, and compared them with theresults available from the single reported series of 25 patientswith ALPPS by Dr Shnitzbauer and colleagues. I would point

out that the MD Anderson group has the nation’s largest experi-ence with PVE that includes the segment 4 branches and that ittakes an experienced interventional radiology group to avoid

compromising flow to the left-lateral segment while occludingthe segment 4 branches. Obviously, comparing 2 groups that arenot matched is difficult, but it does illustrate some points.

Morbidity and mortality appear less with the PVE approach, theincrease in FLR is comparable, and patients who develop extrahe-patic disease post-PVE are spared an unnecessary procedure. The

134 Shindoh et al Discussion J Am Coll Surg

authors are to be congratulated on their excellent results. I haveseveral questions for the authors.

1. You have included 2-stage procedures in which the left lateralsegment is cleared of disease and then, 6 to 8 weeks later, a right

trisegmentectomy is performed. These 2-stage patients were notincluded in the Shnitzbauer paper, although they may be themost appropriate for ALPPS because they will need 2 open

procedures anyway. Should those patients have been excludedfrom this study to make the comparison more valid?

2. Additionally, it appears that in your 2-stage procedures, you

clear the left lateral segment of disease and then postoperativelyperform PVE. Why not perform right portal vein ligation at theinitial operation when the left lateral segment is cleared?

3. We have performed ALPPS on several patients who had extensive

bilateral metastatic disease, including the left lateral segment, andwould require 2-stage hepatectomy, which would result inleaving 10% to 15% of total liver volume if done as a single-

stage procedure.Wewould not use ALPPS nor recommend usingALPPS in any patient in whomPVE alone could be used. There isno doubt that the increase in liver volume seen with ALPPS in the

10-day interval is rapid and, at least in my mind, is greater thanwhat we eventually achieve with PVE, and may allow a 2-stageprocedure to be done within a single hospital stay. The downside

is the potential for complications from the first operation and thefact that the second operation is more difficult than one mightthink. At the second operation, due to the hypertrophy that hasoccurred, there is limited space and also, there is a fairly inflam-

matory operative field. What has your experience at MD Ander-son been with ALPPS?

DR THOMAS ALOIA: You are right about the differences in termsof 2 stages in the ALPPS publication. Three of the 25 patients, or12%, required a concomitant left lateral bisegment tumor resec-

tion, but it’s unclear whether that would have required an opera-tion on its own or not. We compared this with a cohort of oursthat included 20% of patients with 2-stage operations. In our expe-

rience, because these cases are more difficult, their inclusion in ourpart of the series actually favors ALPPS. For example, if we dropour 2-stage patients out, our mortality rate would drop to 2%,

so that would favor them. That having been said, we are evolvingour 2-stage approach by performing the first-stage operation using

a minimally invasive surgical technique. We feel this has 2 benefits.First of all, the patients can go to PVE about 3 or 4 days after theoperation. We do it in a single admission. And then, when we

come back for the second-stage operation, the adhesions are almostnil. Regardless of how you do the approach, ALPPS or PVE or2 stage, the adhesions are a significant issue. We would prefer to

go through fibrous adhesions than inflammatory adhesions.In terms of ligation of the portal vein vs embolization, we prefer

PVE for 3 reasons. We think it’s a better driver of hypertrophy.And there are several recent translational studies that confirm

that. We can address segment 4, as you say, with the PVE, andthat wouldn’t be addressed with a ligation. And we avoid dissectionwithin the porta hepatis; we leave the porta hepatis alone for the

follow-up operation. In terms of the rate of hypertrophy vs themagnitude of hypertrophy, we may concede that the rate of hyper-trophy is higher after ALPPS, but I think we get to the same

endpoint. We believe that the wait time is actually beneficial onco-logically. Multiple surgery centers are coming out with publicationsin the next year that have adopted our technique, including theBerlin group. And all of them are reproducing a 60% to 70%

magnitude hypertrophy. For centers that are not routinelyachieving this rate, we suggest meeting with your radiologists. Ithink we don’t give them enough credit for wanting to be up to

date and advancing their own techniques. In almost all busy livercenters that are doing ALPPS or 2-stage resections, interventionalradiologists are routinely cannulating arteries smaller than segment

4 portal vein branches and delivering embolic microspheres, witha significant risk associated with nontarget embolization. If itmeans a 50% reduction in mortality rate, and we trust them to

do a transarterial chemoembolization, shouldn’t we trust them todo a PVE? And, finally, to answer your question about how weuse ALPPS, we are very concerned about the dissemination ofthis technique and personal communication reporting 75% bile

leak rate and 50% mortality rate as this is moved from the originalcenters out to other centers. So we are approaching it cautiously.Our plan is to use the technique in patients in whom we have

a technical inability to get a PVE. But since the publication ofthis series, we have not encountered that patient yet.