Limits...
Intraoperative Conversion to ALPPS in a Case of Intrahepatic Cholangiocarcinoma.

Oldhafer F, Ringe KI, Timrott K, Kleine M, Ramackers W, Cammann S, Jäger MD, Klempnauer J, Bektas H, Vondran FW - Case Rep Surg (2015)

Bottom Line: Unfortunately, already 2.5 months after resection the patient had developed new tumor lesions found by the follow-up CT-scan.Discussion.Conclusion.

View Article: PubMed Central - PubMed

Affiliation: Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, 30625 Hannover, Germany.

ABSTRACT
Background. Surgical resection remains the best treatment option for intrahepatic cholangiocarcinoma (ICC). Two-stage liver resection combining in situ liver transection with portal vein ligation (ALPPS) has been described as a promising method to increase the resectability of liver tumors also in the case of ICC. Presentation of Case. A 46-year-old male patient presented with an ICC-typical lesion in the right liver. The indication for primary liver resection was set and planed as a right hepatectomy. In contrast to the preoperative CT-scan, the known lesion showed further progression in a macroscopically steatotic liver. Therefore, the decision was made to perform an ALPPS-procedure to avoid an insufficient future liver remnant (FLR). The patient showed an uneventful postoperative course after the first and second step of the ALPPS-procedure, with sufficient increase of the FLR. Unfortunately, already 2.5 months after resection the patient had developed new tumor lesions found by the follow-up CT-scan. Discussion. The presented case demonstrates that an intraoperative conversion to an ALPPS-procedure is safely applicable when the FLR surprisingly seems to be insufficient. Conclusion. ALPPS should also be considered a treatment option in well-selected patients with ICC. However, the experience concerning the outcome of ALPPS in case of ICC remains fairly small.

No MeSH data available.


Related in: MedlinePlus

Pre- and postoperative CT-scan of the liver. Preoperative CT-scan depicting the tumor lesion (marked red) within the right liver lobe (a). Furthermore, the resected liver portion (marked green) and the resulting future liver remnant (FLR; marked blue) are shown. (b) CT-volumetry 10 days after the first step of ALPPS resulted in a significant increase of the FLR (marked by dotted yellow line). The extended right liver lobe (wrapped in a silicone matting) meanwhile showed signs of necrosis following ligation of the right portal vein.
© Copyright Policy - open-access
Related In: Results  -  Collection


getmorefigures.php?uid=PMC4663318&req=5

fig1: Pre- and postoperative CT-scan of the liver. Preoperative CT-scan depicting the tumor lesion (marked red) within the right liver lobe (a). Furthermore, the resected liver portion (marked green) and the resulting future liver remnant (FLR; marked blue) are shown. (b) CT-volumetry 10 days after the first step of ALPPS resulted in a significant increase of the FLR (marked by dotted yellow line). The extended right liver lobe (wrapped in a silicone matting) meanwhile showed signs of necrosis following ligation of the right portal vein.

Mentions: The operation was started as to perform a right hepatectomy and intraoperative ultrasound was used to reevaluate the liver lesion. In contrast to the preoperative CT-scan, the known lesion in the right lobe of the liver was found to additionally infiltrate segment IVa, which was expected to be preserved; thus extended right hepatectomy would have been necessary to achieve tumor-free margins. Therefore, the liver was thoroughly reevaluated and deemed steatotic to a significant degree due to macroscopically visible fat lesions confirmed later by histology. Performing a right trisegmentectomy, an inadequate future liver remnant (FLR) would have been unavoidable. In conclusion, the decision was made to perform an ALPPS-procedure to enable safe resection of the ICC. Consequently, the hepatoduodenal ligament was dissected to isolate the right hepatic artery, portal vein, and bile duct. Then the right hepatic vein was isolated. After transection of the right portal vein, the hepatic parenchyma was dissected between segment II/III and segment IV. Small hepatic veins draining from the right liver into the vena cava likewise were transected. The right liver lobe was then wrapped in a silicone matting to prevent adhesions (Figure 1). The patient required no transfusions of packed red blood cells (pRBC) or fresh frozen plasma (FFP) and showed an uneventful postoperative recovery after the first step of the ALPPS-procedure with discharge from the intensive care unit (ICU) within 3 days. A retrospective volumetry of the FLR showed a volume of 291 cm3 representing approximately 21% of the total liver volume and a FLR/body weight ratio of 0.28 (Figure 1).


Intraoperative Conversion to ALPPS in a Case of Intrahepatic Cholangiocarcinoma.

Oldhafer F, Ringe KI, Timrott K, Kleine M, Ramackers W, Cammann S, Jäger MD, Klempnauer J, Bektas H, Vondran FW - Case Rep Surg (2015)

Pre- and postoperative CT-scan of the liver. Preoperative CT-scan depicting the tumor lesion (marked red) within the right liver lobe (a). Furthermore, the resected liver portion (marked green) and the resulting future liver remnant (FLR; marked blue) are shown. (b) CT-volumetry 10 days after the first step of ALPPS resulted in a significant increase of the FLR (marked by dotted yellow line). The extended right liver lobe (wrapped in a silicone matting) meanwhile showed signs of necrosis following ligation of the right portal vein.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4663318&req=5

fig1: Pre- and postoperative CT-scan of the liver. Preoperative CT-scan depicting the tumor lesion (marked red) within the right liver lobe (a). Furthermore, the resected liver portion (marked green) and the resulting future liver remnant (FLR; marked blue) are shown. (b) CT-volumetry 10 days after the first step of ALPPS resulted in a significant increase of the FLR (marked by dotted yellow line). The extended right liver lobe (wrapped in a silicone matting) meanwhile showed signs of necrosis following ligation of the right portal vein.
Mentions: The operation was started as to perform a right hepatectomy and intraoperative ultrasound was used to reevaluate the liver lesion. In contrast to the preoperative CT-scan, the known lesion in the right lobe of the liver was found to additionally infiltrate segment IVa, which was expected to be preserved; thus extended right hepatectomy would have been necessary to achieve tumor-free margins. Therefore, the liver was thoroughly reevaluated and deemed steatotic to a significant degree due to macroscopically visible fat lesions confirmed later by histology. Performing a right trisegmentectomy, an inadequate future liver remnant (FLR) would have been unavoidable. In conclusion, the decision was made to perform an ALPPS-procedure to enable safe resection of the ICC. Consequently, the hepatoduodenal ligament was dissected to isolate the right hepatic artery, portal vein, and bile duct. Then the right hepatic vein was isolated. After transection of the right portal vein, the hepatic parenchyma was dissected between segment II/III and segment IV. Small hepatic veins draining from the right liver into the vena cava likewise were transected. The right liver lobe was then wrapped in a silicone matting to prevent adhesions (Figure 1). The patient required no transfusions of packed red blood cells (pRBC) or fresh frozen plasma (FFP) and showed an uneventful postoperative recovery after the first step of the ALPPS-procedure with discharge from the intensive care unit (ICU) within 3 days. A retrospective volumetry of the FLR showed a volume of 291 cm3 representing approximately 21% of the total liver volume and a FLR/body weight ratio of 0.28 (Figure 1).

Bottom Line: Unfortunately, already 2.5 months after resection the patient had developed new tumor lesions found by the follow-up CT-scan.Discussion.Conclusion.

View Article: PubMed Central - PubMed

Affiliation: Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, 30625 Hannover, Germany.

ABSTRACT
Background. Surgical resection remains the best treatment option for intrahepatic cholangiocarcinoma (ICC). Two-stage liver resection combining in situ liver transection with portal vein ligation (ALPPS) has been described as a promising method to increase the resectability of liver tumors also in the case of ICC. Presentation of Case. A 46-year-old male patient presented with an ICC-typical lesion in the right liver. The indication for primary liver resection was set and planed as a right hepatectomy. In contrast to the preoperative CT-scan, the known lesion showed further progression in a macroscopically steatotic liver. Therefore, the decision was made to perform an ALPPS-procedure to avoid an insufficient future liver remnant (FLR). The patient showed an uneventful postoperative course after the first and second step of the ALPPS-procedure, with sufficient increase of the FLR. Unfortunately, already 2.5 months after resection the patient had developed new tumor lesions found by the follow-up CT-scan. Discussion. The presented case demonstrates that an intraoperative conversion to an ALPPS-procedure is safely applicable when the FLR surprisingly seems to be insufficient. Conclusion. ALPPS should also be considered a treatment option in well-selected patients with ICC. However, the experience concerning the outcome of ALPPS in case of ICC remains fairly small.

No MeSH data available.


Related in: MedlinePlus