International Journal of Surgery 12 (2014) 1020e1022
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
ALPPS and similar resection procedures in treating extensive hepatic metastases: Our own experiences and critical discussion* Achim Troja*, Karl Khatib-Chahidi, Nader El-Sourani, Dalibor Antolovic, Hans-Rudolf Raab European Medical School Oldenburg, University Department for General and Visceral Surgery, Klinikum Oldenburg, Germany
h i g h l i g h t s What is already known on this topic? We described our experiences with this special extended procedure of liver resection as an ultimate approach for malignancies of the liver. What this study adds? We added information on the oncological outcomes and the perioperative morbidity for this procedure. R0-resection could be achieved in all patients.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 May 2014 Received in revised form 4 July 2014 Accepted 10 July 2014 Available online 15 July 2014
Background: The combination of right sided portal vein ligation and hepatic parenchymal transection thus inducing a hypertrophy of the left or left lateral sector is an innovative treatment option in treating locally advanced hepatic tumors or hepatic metastases. The available published data regarding this procedure is weak. We analyzed our own data regarding tumor recurrence and complications. The data was then used to be critically analyzed using the available published literature. Methods: We treated n ¼ 5 patients with an ALPPS (associating liver partition and portal vein ligation for staged hepatectomy). The follow-up was 3 years. We analyzed the perioperative period, complications, mortality and oncological survival rate. Results: In all patients (n ¼ 5) a R0-resection was achieved. N ¼ 1 patient died postoperatively. N ¼ 1 patient died 6 month later due to a pulmonary embolism. N ¼ 3 patients had a tumor recurrence within 6 months. Conclusion: Selected patients can be successfully treated by ALPPS in terms of an R0-resection. However, risk of tumor recurrence and rate of complications are high. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: ALPPS In-situ split Major liver resection Liver metastasis
1. Introduction In patients with extensive hepatic metastases or a large primary cancer of the liver, R0-resection is the only treatment option that gives a possibility of cure. Currently, the two-stage-hepatectomy by combining portal vein ligation with in-situ split of liver (ALPPS) followed by repaid hypertrophy of left lateral section of liver to allow subsequent resection is a hot topic in liver surgery [1]. This technique has been well-described and enables liver resection to be
carried out for patients with advanced hepatic malignancies with high risks of developing postoperative hepatic failure/insufficiency due to inadequate future liver remnants [2e4]. Different techniques have been described to induce hypertrophy of hepatic tissues for these patients. This can be achieved through transcatheter embolization or alternatively through surgical portal vein ligation [5,6]. The aim of our study is to evaluate our data, especially on oncological results of ALPPS, and its possible complications.
2. Material and methods *
This study and manuscript is concepted in accordance with the declaration of Helsinki. * Corresponding author. University Department for General and Visceral Surgery, European Medical School Oldenburg, Klinikum Oldenburg, Rahel-Strauss-Str.10, 26133 Oldenburg, Germany. E-mail address: [email protected] (A. Troja). http://dx.doi.org/10.1016/j.ijsu.2014.07.006 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
We analyzed and evaluated the data of our patients who underwent ALPPS. In the past 5 years, there were more than 350 hepatic resections in our university hospital. 5 of these resections were ALPPS. The necessity of an ALPPS procedure was based on the
A. Troja et al. / International Journal of Surgery 12 (2014) 1020e1022
preoperative planning by 3-phase CT and on the estimation of the volume of the future liver remnant. The patients were followed-up regularly after the operation. We did not carry out routine 3D liver reconstruction. The surgical technique conformed with the technique as described in the published literature [7,8]. Laparotomy was via an inverted “L” incision, and the liver was fully mobilized. After ruling out peritoneal carcinomatosis and intraabdominal metastases, intraoperative ultrasound was performed. Lymphadenectomy of the hepatoduodenal ligament then followed. The right liver was then mobilized from the inferior vena cava, and the hepatic artery, portal vein and common hepatic duct were prepared. The right portal vein distal to the bifurcation was then dissected and sutured, followed by hepatic parenchymal transection. If there was tumor in the future liver remnant, an atypical hepatic resection was carried out. To prevent post-operative adhesions, omentoplasty was performed in 2 patients. CT was done 7e10 days after the initial surgery to evaluate the degree of liver hypertrophy in the future liver remnant. If the volume of the future liver remnant was considered sufficient, the second stage surgery was carried out (extended liver resection after ligation and division of the previously prepared structures including the right hepatic artery, right and middle hepatic veins and right hepatic duct). 3. Results Five patients were treated by ALPPS (Table 1) and in all the patients a R0-resection was achieved (Table 2). One patient died postoperatively due to hemorrhagic shock. This patient was a member of “Jehova's Witness” who refused blood transfusion. In two patients, recurrence of liver metastases occurred within 8 weeks after ALPPS. In one of these patients who had a primary gastrointestinal tumor (GIST) of the small bowel, hepatic metastases occurred after only 6 months (Table 2). One patient who was tumor free, died 8 months after ALPPS due to pulmonary embolism following an orthopedic operation. All patients experienced surgical related complications (Table 3). The time between the first and the second surgery was 14 days in four patients and 21 days in one patient. Regarding the surgical techniques three patients received a “classical” ALPPs procedure. In one patient a catheter guided transhepatic embolization of the left portal vein with vascular plugs and microspheres (700e900 mm) was performed. Because of insufficient hypertrophy of the left hepatic section, a two-staged operation was added. In another patient a three-staged procedure was performed. During the first stage, subsegmental resection of segment 3 with dissection of the portal vein branch supplying segment 1 and 4, transection of the hepatic parenchyma between the left lateral section and segment 4 were performed. During the second stage the tumors were resected by resection of segments 4, 5, 6 and atypical segmental resection of segment 8. This was necessary because hypertrophy of the left lateral section was not sufficient. After hypertrophy of the left-lateral section and the
Table 1 Patient data. Patient
Sex
Age
Primary tumor
1 2
M W
38 72
3 4
M M
65 52
GIST small bowel ICC pT2a pN1 Mo L1 V0 G2 Barrett-Ca ypT2 ypN2 R0 Rectal cancer pT2 pN0 pM1
Tumor stage
5
M
71
Colon cancer
pT4 pN0 M1
Chemotherapy Imatinib/sunitinib None 6 cycles Cisplatin/5-FU 14 cycles FOLFIRI þ Bevacizumab None
1021
Table 2 Surgical procedure and time interval. Patient
Operation
Time-interval
1 2 3 4
Extended right hemihepatectomy Segmentectomy 4,5,8 þ Subsegmentectomy 3 Extended right hemihepatectomy Extended right hemihepatectomy þ atypical left lateral resection Sg. 2,3 Extended right hemihepatectomy
14 21 14 14
5
d d d d
19 d
remnant right liver the remaining right liver was resected in a third stage, thus leaving the left lateral section (Sg. 2,3). Renal insufficiency needing dialysis did not occur in any patient. Liver insufficiency occurred in 2 patients who presented with edema and hyperbilirubinema. The median hospital stay was 52 days (Figs. 1 and 2). 4. Discussion R0-resection is a treatment option aiming at cure for patients suffering from colorectal liver metastases or a large primary hepatic cancer. The limiting factor is the volume of the future liver remnant after resection. The phenomenon of hypertrophy of the liver is long known. This can be achieved by embolization or ligation of the right or left portal blood flow [9]. However, these procedures also run the risk of tumor progression between the time of embolization and resection [10,11]. With ALPPS, the time taken between inducing hypertrophy and resection can be reduced to 10e14 days when compared with 6 weeks in portal vein embolization. This may reduce the risk of further metastatic disease [4,12]. The rate of liver hypertrophy for ALPPS (the combination of ligation of the right portal branch, hepatic parenchymal transection and devascularisation of segment IV) is superior to portal vein occlusion or embolization [4]. In concordance with the data available in the published literature we were able to induce rapid hypertrophy to the left lateral section and were able to perform resection in 14 days in four patients, and no patient died from hepatic failure. In two out of five patients, early liver recurrence (within 8 weeks) was detected. In the paper by Oldhafer et al. [7], one patient developed new metastases after 6 month. One of our patients had underlying gastrointestinal tumor. A probable explanation for early tumor recurrence is in the primary tumor (GIST compared to adenocarcinoma). The possibility of tumor progression with induction of liver hypertrophy has already been discussed [13e15]. Oldhafer et al. did not only describe recurrence of hepatic metastases but also described distant metastases. A possible hypothesis is that the induction of liver hypertrophy is due to release of growth factors which increase the chance of intrahepatic/extrahepatic metastases. In addition, immunosuppression due to the extensive surgical resection triggers growth and tumor spread. There is no available data to suggest whether adjuvant chemotherapy is useful or not.
Table 3 Complications and oncological outcome. Patient
Dindo-Clavien classification
Hospital stay
Mortality
Recurrence
1 2 3 4 5
III V II d II d II d
30 34 69 91 37
N Y N N N
6 month later
d d, death d d d
4 weeks later 8 weeks later n
1022
A. Troja et al. / International Journal of Surgery 12 (2014) 1020e1022
the study and participate in its design and coordination. All authors read and approved the manuscript.
Serum Bilirubin
5 4.5
Serum Bilirubin in mg/dl
4
Conflicts of interest
3.5 3
The authors declare that they have no competing interests.
2.5 2
Acknowledgments
1.5 1
None.
0.5
0 Serum-bilirubin OP day
Serum-bilirubin 7.d post-OP
Serum-bilirubin 14.d post-OP
Days after surgery
Fig. 1. Post-operative serum bilirubine levels.
Serum creatinine 1.4
Serum creatinine in mg/dl
1.2 1 0.8 0.6 0.4 0.2 0 Serum creatinine OP day
Serum creatinine 7. d post-OP Serum creatinine 14. d post-OP Days after surgery
Fig. 2. Post-operative serum creatinine levels.
The available literature on ALPPS shows that patients have to be carefully selected [16]. To what extent patients with colorectal hepatic metastases and or a large primary hepatic tumor could profit from ALPPS cannot be certain at this point [17]. 5. Conclusion In conclusion the analysis of our data supported early recurrence and metastases after ALPPS. The underlying mechanism is still not fully understood. R0-resection in selected patients by ALPPS is possible. It is crucial to find out what patients can benefit from this extensive procedure. Ethical approval None. Funding None. Authors contributions AT designed the idea and wrote the manuscript. KKC participated in recruitment of the data. NES participated in the design of the study and did the language check. DA participated in the design of the study and helped to draft the manuscript. HRR conceived of
References [1] A.A. Schnitzbauer, S.A. Lang, H. Goessmann, S. Nadalin, J. Baumgart, € rbelt, A. Kroemer, S.A. Farkas, S. Fichtner-Feigl, T. Lorf, A. Goralcyk, R. Ho €nigsrainer, H. Lang, M. Loss, P. Rümmele, M.N. Scherer, W. Padberg, A. Ko A. Obed, H.J. Schlitt, 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. 255 (3) (2012 Mar) 405e414. [2] O.N. Tucker, N. Heaton, The ‘small for size’ liver syndrome, Curr. Opin. Crit. Care 11 (2) (2005 Apr) 150e155. Review. [3] O.J. Torres, S. Fernandes Ede, C.V. Oliveira, C.X. Lima, F.L. Waechter, J.M. Moraes-Junior, M.M. Linhares, R.D. Pinto, P. Herman, M.A. Machado, Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): the Brazilian experience, Arq. Bras. Cir. Dig. 26 (1) (2013 JaneMar) 40e43. [4] O.J. Torres, J.M. Moraes-Junior, N.C. Lima e Lima, A.M. Moraes, Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): a new approach in liver resections, Arq. Bras. Cir. Dig. 25 (4) (2012 OcteDec) 290e292. [5] B. Aussilhou, M. Lesurtel, A. Sauvanet, O. Farges, S. Dokmak, N. Goasguen, A. Sibert, V. Vilgrain, J. Belghiti, Right portal vein ligation is as efficient as portal vein embolization to induce hypertrophy of the left liver remnant, J. Gastrointest. Surg. 12 (2) (2008 Feb) 297e303. [6] D.C. Broering, C. Hillert, G. Krupski, L. Fischer, L. Mueller, E.G. Achilles, J. Schulte am Esch, X. Rogiers, Portal vein embolization vs. portal vein ligation for induction of hypertrophy of the future liver remnant, J. Gastrointest. Surg. 6 (6) (2002 NoveDec) 905e913. Discussion 913. [7] K.J. Oldhafer, M. Donati, R.M. Jenner, A. Stang, G.A. Stavrou, ALPPS for patients with colorectal liver metastases: effective liver hypertrophy, but early tumor recurrence, World J. Surg. 38 (6) (2014 Jun) 1504e1509. [8] M.A. Machado, F.F. Makdissi, R.C. Surjan, G.T. Kappaz, N. Yamaguchi, Twostage laparoscopic liver resection for bilateral colorectal liver metastasis, Surg. Endosc. 24 (8) (2010 Aug) 2044e2047. [9] M. Nagino, J. Kamiya, H. Nishio, T. Ebata, T. Arai, Y. Nimura, Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up, Ann. Surg. 243 (3) (2006 Mar) 364e372. [10] K. Tanaka, H. Shimada, K. Matsuo, M. Ueda, I. Endo, S. Togo, Remnant liver regeneration after two-stage hepatectomy for multiple bilobar colorectal metastases, Eur. J. Surg. Oncol. 33 (3) (2007 Apr) 329e335. Epub 2006 Nov 30. ~ es, P.A. Clavien, Playing Play-Doh to prevent postoperative liver [11] E. De Santiban failure: the “ALPPS” approach, Ann. Surg. 255 (3) (2012 Mar) 415e417. [12] W.T. Knoefel, I. Gabor, A. Rehders, A. Alexander, M. Krausch, J. Schulte am Esch, G. Fürst, S.A. Topp, In situ liver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection, Br. J. Surg. 100 (3) (2013 Feb) 388e394. [13] D. Elias, T. De Baere, A. Roche, Mducreux, J. Leclere, P. Lasser, During liver regeneration following right portal embolization the growth rate of liver metastases is more rapid than that of the liver parenchyma, Br. J. Surg. 86 (6) (1999 Jun) 784e788. [14] N. Kokudo, K. Tada, M. Seki, H. Ohta, K. Azekura, M. Ueno, K. Ohta, T. Yamaguchi, T. Matsubara, T. Takahashi, T. Nakajima, T. Muto, T. Ikari, A. Yanagisawa, Y. Kato, Proliferative activity of intrahepatic colorectal metastases after preoperative hemihepatic portal vein embolization, Hepatology 34 (2) (2001 Aug) 267e272. [15] V. Pamecha, A. Levene, F. Grillo, N. Woodward, A. Dhillon, B.R. Davidson, Effect of portal vein embolisation on the growth rate of colorectal liver metastases, Br. J. Cancer 100 (4) (2009 Feb 24) 617e622. [16] S.A. Lang, M. Loss, H.J. Schlitt, “In-situ split” (ISS) liver resection: new aspects of technique and indication, Zentralbl Chir. 139 (2) (2014 Apr) 212e219. €nigsrainer, R. Ladurner, A. Ko €nigsrainer, S. Nadalin, ALPPS [17] J. Li, P. Girotti, I. Ko in right trisectionectomy: a safe procedure to avoid postoperative liver failure? J. Gastrointest. Surg. 17 (5) (2013 May) 956e961.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
ALPPS and similar resection procedures in treating extensive hepatic metastases: Our own experiences and critical discussion* Achim Troja*, Karl Khatib-Chahidi, Nader El-Sourani, Dalibor Antolovic, Hans-Rudolf Raab European Medical School Oldenburg, University Department for General and Visceral Surgery, Klinikum Oldenburg, Germany
h i g h l i g h t s What is already known on this topic? We described our experiences with this special extended procedure of liver resection as an ultimate approach for malignancies of the liver. What this study adds? We added information on the oncological outcomes and the perioperative morbidity for this procedure. R0-resection could be achieved in all patients.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 May 2014 Received in revised form 4 July 2014 Accepted 10 July 2014 Available online 15 July 2014
Background: The combination of right sided portal vein ligation and hepatic parenchymal transection thus inducing a hypertrophy of the left or left lateral sector is an innovative treatment option in treating locally advanced hepatic tumors or hepatic metastases. The available published data regarding this procedure is weak. We analyzed our own data regarding tumor recurrence and complications. The data was then used to be critically analyzed using the available published literature. Methods: We treated n ¼ 5 patients with an ALPPS (associating liver partition and portal vein ligation for staged hepatectomy). The follow-up was 3 years. We analyzed the perioperative period, complications, mortality and oncological survival rate. Results: In all patients (n ¼ 5) a R0-resection was achieved. N ¼ 1 patient died postoperatively. N ¼ 1 patient died 6 month later due to a pulmonary embolism. N ¼ 3 patients had a tumor recurrence within 6 months. Conclusion: Selected patients can be successfully treated by ALPPS in terms of an R0-resection. However, risk of tumor recurrence and rate of complications are high. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: ALPPS In-situ split Major liver resection Liver metastasis
1. Introduction In patients with extensive hepatic metastases or a large primary cancer of the liver, R0-resection is the only treatment option that gives a possibility of cure. Currently, the two-stage-hepatectomy by combining portal vein ligation with in-situ split of liver (ALPPS) followed by repaid hypertrophy of left lateral section of liver to allow subsequent resection is a hot topic in liver surgery [1]. This technique has been well-described and enables liver resection to be
carried out for patients with advanced hepatic malignancies with high risks of developing postoperative hepatic failure/insufficiency due to inadequate future liver remnants [2e4]. Different techniques have been described to induce hypertrophy of hepatic tissues for these patients. This can be achieved through transcatheter embolization or alternatively through surgical portal vein ligation [5,6]. The aim of our study is to evaluate our data, especially on oncological results of ALPPS, and its possible complications.
2. Material and methods *
This study and manuscript is concepted in accordance with the declaration of Helsinki. * Corresponding author. University Department for General and Visceral Surgery, European Medical School Oldenburg, Klinikum Oldenburg, Rahel-Strauss-Str.10, 26133 Oldenburg, Germany. E-mail address: [email protected] (A. Troja). http://dx.doi.org/10.1016/j.ijsu.2014.07.006 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
We analyzed and evaluated the data of our patients who underwent ALPPS. In the past 5 years, there were more than 350 hepatic resections in our university hospital. 5 of these resections were ALPPS. The necessity of an ALPPS procedure was based on the
A. Troja et al. / International Journal of Surgery 12 (2014) 1020e1022
preoperative planning by 3-phase CT and on the estimation of the volume of the future liver remnant. The patients were followed-up regularly after the operation. We did not carry out routine 3D liver reconstruction. The surgical technique conformed with the technique as described in the published literature [7,8]. Laparotomy was via an inverted “L” incision, and the liver was fully mobilized. After ruling out peritoneal carcinomatosis and intraabdominal metastases, intraoperative ultrasound was performed. Lymphadenectomy of the hepatoduodenal ligament then followed. The right liver was then mobilized from the inferior vena cava, and the hepatic artery, portal vein and common hepatic duct were prepared. The right portal vein distal to the bifurcation was then dissected and sutured, followed by hepatic parenchymal transection. If there was tumor in the future liver remnant, an atypical hepatic resection was carried out. To prevent post-operative adhesions, omentoplasty was performed in 2 patients. CT was done 7e10 days after the initial surgery to evaluate the degree of liver hypertrophy in the future liver remnant. If the volume of the future liver remnant was considered sufficient, the second stage surgery was carried out (extended liver resection after ligation and division of the previously prepared structures including the right hepatic artery, right and middle hepatic veins and right hepatic duct). 3. Results Five patients were treated by ALPPS (Table 1) and in all the patients a R0-resection was achieved (Table 2). One patient died postoperatively due to hemorrhagic shock. This patient was a member of “Jehova's Witness” who refused blood transfusion. In two patients, recurrence of liver metastases occurred within 8 weeks after ALPPS. In one of these patients who had a primary gastrointestinal tumor (GIST) of the small bowel, hepatic metastases occurred after only 6 months (Table 2). One patient who was tumor free, died 8 months after ALPPS due to pulmonary embolism following an orthopedic operation. All patients experienced surgical related complications (Table 3). The time between the first and the second surgery was 14 days in four patients and 21 days in one patient. Regarding the surgical techniques three patients received a “classical” ALPPs procedure. In one patient a catheter guided transhepatic embolization of the left portal vein with vascular plugs and microspheres (700e900 mm) was performed. Because of insufficient hypertrophy of the left hepatic section, a two-staged operation was added. In another patient a three-staged procedure was performed. During the first stage, subsegmental resection of segment 3 with dissection of the portal vein branch supplying segment 1 and 4, transection of the hepatic parenchyma between the left lateral section and segment 4 were performed. During the second stage the tumors were resected by resection of segments 4, 5, 6 and atypical segmental resection of segment 8. This was necessary because hypertrophy of the left lateral section was not sufficient. After hypertrophy of the left-lateral section and the
Table 1 Patient data. Patient
Sex
Age
Primary tumor
1 2
M W
38 72
3 4
M M
65 52
GIST small bowel ICC pT2a pN1 Mo L1 V0 G2 Barrett-Ca ypT2 ypN2 R0 Rectal cancer pT2 pN0 pM1
Tumor stage
5
M
71
Colon cancer
pT4 pN0 M1
Chemotherapy Imatinib/sunitinib None 6 cycles Cisplatin/5-FU 14 cycles FOLFIRI þ Bevacizumab None
1021
Table 2 Surgical procedure and time interval. Patient
Operation
Time-interval
1 2 3 4
Extended right hemihepatectomy Segmentectomy 4,5,8 þ Subsegmentectomy 3 Extended right hemihepatectomy Extended right hemihepatectomy þ atypical left lateral resection Sg. 2,3 Extended right hemihepatectomy
14 21 14 14
5
d d d d
19 d
remnant right liver the remaining right liver was resected in a third stage, thus leaving the left lateral section (Sg. 2,3). Renal insufficiency needing dialysis did not occur in any patient. Liver insufficiency occurred in 2 patients who presented with edema and hyperbilirubinema. The median hospital stay was 52 days (Figs. 1 and 2). 4. Discussion R0-resection is a treatment option aiming at cure for patients suffering from colorectal liver metastases or a large primary hepatic cancer. The limiting factor is the volume of the future liver remnant after resection. The phenomenon of hypertrophy of the liver is long known. This can be achieved by embolization or ligation of the right or left portal blood flow [9]. However, these procedures also run the risk of tumor progression between the time of embolization and resection [10,11]. With ALPPS, the time taken between inducing hypertrophy and resection can be reduced to 10e14 days when compared with 6 weeks in portal vein embolization. This may reduce the risk of further metastatic disease [4,12]. The rate of liver hypertrophy for ALPPS (the combination of ligation of the right portal branch, hepatic parenchymal transection and devascularisation of segment IV) is superior to portal vein occlusion or embolization [4]. In concordance with the data available in the published literature we were able to induce rapid hypertrophy to the left lateral section and were able to perform resection in 14 days in four patients, and no patient died from hepatic failure. In two out of five patients, early liver recurrence (within 8 weeks) was detected. In the paper by Oldhafer et al. [7], one patient developed new metastases after 6 month. One of our patients had underlying gastrointestinal tumor. A probable explanation for early tumor recurrence is in the primary tumor (GIST compared to adenocarcinoma). The possibility of tumor progression with induction of liver hypertrophy has already been discussed [13e15]. Oldhafer et al. did not only describe recurrence of hepatic metastases but also described distant metastases. A possible hypothesis is that the induction of liver hypertrophy is due to release of growth factors which increase the chance of intrahepatic/extrahepatic metastases. In addition, immunosuppression due to the extensive surgical resection triggers growth and tumor spread. There is no available data to suggest whether adjuvant chemotherapy is useful or not.
Table 3 Complications and oncological outcome. Patient
Dindo-Clavien classification
Hospital stay
Mortality
Recurrence
1 2 3 4 5
III V II d II d II d
30 34 69 91 37
N Y N N N
6 month later
d d, death d d d
4 weeks later 8 weeks later n
1022
A. Troja et al. / International Journal of Surgery 12 (2014) 1020e1022
the study and participate in its design and coordination. All authors read and approved the manuscript.
Serum Bilirubin
5 4.5
Serum Bilirubin in mg/dl
4
Conflicts of interest
3.5 3
The authors declare that they have no competing interests.
2.5 2
Acknowledgments
1.5 1
None.
0.5
0 Serum-bilirubin OP day
Serum-bilirubin 7.d post-OP
Serum-bilirubin 14.d post-OP
Days after surgery
Fig. 1. Post-operative serum bilirubine levels.
Serum creatinine 1.4
Serum creatinine in mg/dl
1.2 1 0.8 0.6 0.4 0.2 0 Serum creatinine OP day
Serum creatinine 7. d post-OP Serum creatinine 14. d post-OP Days after surgery
Fig. 2. Post-operative serum creatinine levels.
The available literature on ALPPS shows that patients have to be carefully selected [16]. To what extent patients with colorectal hepatic metastases and or a large primary hepatic tumor could profit from ALPPS cannot be certain at this point [17]. 5. Conclusion In conclusion the analysis of our data supported early recurrence and metastases after ALPPS. The underlying mechanism is still not fully understood. R0-resection in selected patients by ALPPS is possible. It is crucial to find out what patients can benefit from this extensive procedure. Ethical approval None. Funding None. Authors contributions AT designed the idea and wrote the manuscript. KKC participated in recruitment of the data. NES participated in the design of the study and did the language check. DA participated in the design of the study and helped to draft the manuscript. HRR conceived of
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