Two stage hepatectomy (TSH) versus ALPPS for initially unresectable colorectal liver metastases: A systematic review and meta-analysis.

BACKGROUND: Although numerous comparisons between conventional Two Stage Hepatectomy (TSH) and Associating Liver Partition and Portal Vein Ligation for staged hepatectomy (ALPPS) have been reported, the heterogeneity of malignancies previously compared represents an important source of selection bias. This systematic review and meta-analysis aimed to compare perioperative and oncological outcomes between TSH and ALPPS to treat patients with initially unresectable colorectal liver metastases (CRLM). METHODS: Main electronic databases were searched using medical subject headings for CRLM surgically treated with TSH or ALPPS. Patients treated for primary or secondary liver malignancies other than CRLM were excluded. RESULTS: A total of 335 patients from 5 studies were included. Postoperative major complications were higher in the ALPPS group (relative risk [RR] 1.46, 95% confidence interval [CI] 1.04-2.06, I2 = 0%), while no differences were observed in terms of perioperative mortality (RR 1.53, 95% CI 0.64-3.62, I2 = 0%). ALPPS was associated with higher completion of hepatectomy rates (RR 1.32, 95% CI 1.09-1.61, I2 = 85%), as well as R0 resection rates (RR 1.61, 95% CI 1.13-2.30, I2 = 40%). Nevertheless, no significant differences were achieved between groups in terms of overall survival (OS) (RR 0.93, 95% CI 0.68-1.27, I2 = 52%) and disease-free survival (DFS) (RR 1.08, 95% CI 0.47-2.49, I2 = 54%), respectively. CONCLUSION: ALPPS and TSH to treat CRLM seem to have comparable operative risks in terms of mortality rates. No definitive conclusions regarding OS and DFS can be drawn from the results.

Ruptured subcapsular liver hematoma as a rare complication of HELLP syndrome. A therapeutic challenge.

HELLP syndrome (HS), a low-incidence condition of uncertain pathogenesis associated with pregnancy hypertensive syndromes, is characterized by hemolysis, elevated liver enzymes and low platelet count. Ruptured subcapsular liver hematoma complicated with hemoperitoneum is an uncommon but very serious condition where early recognition and multidisciplinary management are key to reduce its associated maternal, infant mortality rate. Symptoms are nonspecific, characterized by por epigastric pain, nausea and vomiting; clinical suspicion and appropriate imaging studies are of crucial importance. We report the case of a 36-year-old primiparous woman at 39 weeks of gestation. She was admitted for early membrane rupture, with delivery complicated by retained placenta. During the immediate puerperium she had blood pressure > 140/90 mmHg, epigastric pain and vomiting, which required respiratory and hemodynamic support. An exploratory laparotomy was performed that revealed a massive hemoperitoneum as well as CR in the RLL with multifocal active bleeding. The left liver lobe was macroscopically normal. The patient underwent hemoperitoneum drainage and hepatic packing (HP); biopsy findings were consistent with necrosis. Polytransfusion was initiated with blood products and antihemorrhagic agents.

Surgical treatment of liver metastasis from breast cancer.

We report five patients who underwent laparotomy for liver metastasis from breast cancer without extrahepatic spread, with the intention to perform liver resection. All these patients had been subjected to modified radical mastectomy following systemic chemotherapy and periodical consecutive investigations to detect distant spreading. After laparotomy, patients have been regularly followed. Case 1, right trisegmentectomy in a 53-year-old woman, 36.5 months after the mastectomy. In the 17th postoperative month she continues without relapse. Case 2, hepatic artery ligature in a 41-year-old woman, 15 months after the mastectomy. In the 17th postoperative month she died. Case 3, bisegmentectomy (VI-VII) in a 51-year-old woman, 24 months after the mastectomy. In the 17th postoperative month she died. Case 4, exploratory laparotomy in a 51-year-old woman, 91 months after the mastectomy. In the 31th postoperative month she remains alive. Case 5, segmentectomy (IV) in a 59-year-old woman, 112 months after the mastectomy. In the 33th postoperative month she continues without relapse. As a conclusion, the surgical resection of liver metastasis from breast tumors after chemotherapy must be used in selected cases.