ALPPS for Left Trisectionectomy with Reconstruction of the Hepato-caval Junction Using a Peritoneal Patch Under Total Vascular Exclusion.

BACKGROUND: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) may rescue remnant liver hypertrophy after failure of portal vein embolization (PVE).1 Venous reconstruction is unusual during the first step of ALPPS.2 We report herein an ALPPS for colorectal liver metastases with reconstruction of the hepato-caval junction during the first step. METHODS: After failure of left PVE, a total ALPPS procedure was performed to achieve left trisectionectomy. A complete transection of the parenchyma was done to avoid extensive dissection during the second step in the context of the venous reconstruction. Total vascular exclusion (TVE) was applied selectively during venous reconstruction using a peritoneal patch.3 RESULTS: The first step lasted 285 min with 200 ml of blood loss, and 29 min of TVE. On postoperative day (POD) 5 there was a good recovery of liver function [prothrombin time 75%; bilirubin 25 µmol/L]. On POD 14, imaging showed an increase of the future remnant liver volume and function to 50% and 48%, respectively. The second step of ALPPS lasted 120 min, with transfusion of one unit of blood, allowing resection of seven liver metastases. Postoperative course experienced a biliary fistula, the patient was discharged on POD 31 and received adjuvant chemotherapy. There was recurrence of one liver metastasis, treated by percutaneous ablation before later resection of the primary. The patient was free of recurrence 12 months after ALPPS. CONCLUSION: Hepato-caval junction reconstruction can be performed during the first step of an ALPPS procedure, facilitated by the availability of a peritoneum patch.

Safeness of Simultaneous Colonic Resection and Hepatic Radiofrequency Ablation.

Background and Objectives: Previous reports showed an increased risk of infectious complications when liver radiofrequency ablation (RFA) is performed simultaneously to colorectal resection. The aim of this study was to compare early and long-term outcomes of simultaneous versus staged strategy. Methods: Data from colorectal cancer liver metastases consecutively treated by surgery of the primary tumor with an associated liver RFA procedure between January 1, 2010 and January 31, 2020. Patients were divided into two groups: RFA performed during colorectal surgery (simultaneous) or in a different moment (staged). Patients were manually matched (1:1) to minimize influence of known covariates. Results: Seventy-two patients were included. After matching, there was no difference between the two groups in morbidity or mortality. Hospital stay was 2 days shorter in the simultaneous group. Conclusions: Early or long-term outcomes were identical between the two strategies. The simultaneous strategy was associated with a shorter duration of hospitalization although not significant. Simultaneous colorectal resection and liver RFA is safe and must be included in surgeons' armamentarium.

Liver resection for octogenarians in a French center: prolonged hepatic pedicle occlusion and male sex increase major complications.

PURPOSE: The prolonged life expectancy and increase in aging of the population have led surgeons to propose hepatectomy in the elderly population. In this study, we evaluate the surgical outcome of octogenarians in a single French center. METHODS: Between 2000 and 2020, 78 patients over 80 years old were retrospectively analyzed. The risk factors of major complications (Clavien-Dindo ≥ grade IIIa) and patient performance after surgery by using textbook outcome (TO) (no surgical complications, no prolonged hospital stay (≤ 15 days), no readmission ≤90 days after discharge, and no mortality ≤90 days after surgery) were studied. RESULTS: The main surgical indication was for malignancy (96%), including mainly colorectal liver metastases (n = 41; 53%) and hepatocellular carcinoma (n = 22; 28%), and major hepatectomy was performed in 28 patients (36%). There were 6 (8%) postoperative mortalities. The most frequent complications were pulmonary (n = 22; 32%), followed by renal insufficiency (n = 22; 28%) and delirium (n = 16; 21%). Major complications occurred in 19 (24%) patients. On multivariate analysis, the main risk factors for major complications were the median vascular clamping time (0 vs 35; P = 0.04) and male sex (P = 0.046). TO was ultimately achieved in 30 patients (38%), and there was no prognostic factor for achievement of TO. CONCLUSIONS: Hepatectomy in octogenarians is associated with acceptable morbidity and mortality. Meanwhile, prolonged hepatic pedicle clamping should be avoided especially if hepatectomy is planned in a male patient.