ALPPS in neuroendocrine liver metastases not amenable for conventional resection - lessons learned from an interim analysis of the International ALPPS Registry.

BACKGROUND: Surgery is the most effective treatment option for neuroendocrine liver metastases (NELM). This study investigated the role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a novel strategy in treatment of NELM. METHODS: The International ALPPS Registry was reviewed to study patients who underwent ALPPS for NELM. RESULTS: From 2010 to 2017, 954 ALPPS procedures from 135 international centers were recorded in the International ALPPS Registry. Of them, 24 (2.5%) were performed for NELM. Twenty-one patients entered the final analysis. Overall grade ≥3b morbidity was 9% after stage 1 and 27% after stage 2. Ninety-day mortality was 5%. R0 resection was achieved in 19 cases (90%) at stage 2. Median follow-up was 28 (19-48) months. Median disease free survival (DFS) was 17.3 (95% CI: 7.1-27.4) months, 1-year and 2-year DFS was 73.2% and 41.8%, respectively. Median overall survival (OS) was not reached. One-year and 2-year OS was 95.2% and 95.2%, respectively. CONCLUSIONS: ALPPS appears to be a suitable strategy for inclusion in the multimodal armamentarium of well-selected patients with neuroendocrine liver metastases. In light of the morbidity in this initial series and a high rate of disease-recurrence, the procedure should be taken with caution.

Role of laparoscopic right portal vein ligation in planning staged or major liver resection.

BACKGROUND AND AIMS: Right portal vein ligation (PVL) has its recognized role in inducing hypertrophy of future liver remnant (FLR) prior to major liver resection. The aim of this study was to evaluate the safety, feasibility, and effectiveness of laparoscopic right PVL and to explore its applications. METHODS: Laparoscopic right PVL was employed either during staging laparoscopy when a right hepatic trisectionectomy was indicated, leaving a small (<25%) FLR (indication 1), or during a laparoscopic left hepatic lobectomy (left lateral sectionectomy) when a second-stage right hemihepatectomy was to follow (indication 2). A follow up cross-sectional liver imaging was performed 4-6 weeks later with liver volumetry to confirm hypertrophy of the FLR before proceeding to major hepatectomy. RESULTS: Six patients (female, 5), 74-83 years old, underwent a laparoscopic right PVL, of whom 4 patients fulfilled indication 1 while 2 patients fulfilled indication 2. The median operating time for indication 1 was 60 minutes. There were no intra- or postoperative complications, and all procedures were completed laparoscopically. Repeat imaging of the liver demonstrated a median (range) hypertrophy of FLR of 24.5% (range, 20.7-33.1%). The right liver experienced atrophy. CONCLUSIONS: In the hands of the experienced laparoscopic hepatobiliary surgeon, laparoscopic right PVL is feasible and safe, and induces adequate regeneration of the FLR. Laparoscopic right PVL has its applications at the time of staging laparoscopy in patients requiring a right hepatic trisectionectomy in the presence of a small FLR and as part of a staged liver resection in patients with bilobar liver disease that spares segments 1 and 4.

Timing of laparoscopic cholecystectomy for acute cholecystitis: evidence to support a proposal for an early interval surgery.

We evaluated the safety and feasibility of delayed urgent laparoscopic cholecystectomy (LC) performed beyond 72 hours to overcome the logistical difficulties in performing early urgent LC within 72 hours of admission with acute cholecystitis (AC), and to avoid earlier readmission with recurrent AC in patients awaiting delayed interval. Patients admitted with AC were scheduled for urgent LC. Patients who underwent early urgent LC were compared with those who had delayed urgent surgery. Fifty consecutive patients underwent urgent LC for AC within 2 weeks of admission. There were no conversions and no bile duct injuries. Delayed surgery (n=36) neither prolonged operating time (90 vs. 85 minutes), nor increased operative morbidity (9.7% vs. 7.7%) or mortality (2.4% vs. 7.7%) compared with early surgery (n=14). Although delayed surgery was associated with shorter postoperative hospital stay (1 vs. 2 days, P = 0.029), it prolonged total hospital stay (9 vs. 5 days, P < 0.0001). Delay of LC beyond 72 hours neither increases operative difficulty nor prolongs recovery. It might be more cost effective to schedule patients who could not undergo early urgent LC but are responding to conservative treatment for an early interval LC within 2 weeks of presentation with AC.

Spontaneous rupture of the splenic capsule with massive bleeding subsequent to the pringle maneuver during laparoscopic liver resection.

BACKGROUND: The Pringle maneuver has its applications to minimize blood loss during hepatic resection. Splenic rupture during the Pringle maneuver in open liver surgery was described only in few cases. This is the first report of such a complication during laparoscopic surgery. CASE REPORT: A 58-year-old woman sustained major splenic capsular rupture during laparoscopic right lateral hepatic sectionectomy (resection of segments VI to VII) for a colorectal metastasis. Surgery was carried out with the patient in the left lateral position. She became hypotensive during the second application of the Pringle maneuver secondary to spontaneous rupture of the splenic capsule. This was controlled with application of thrombogenic hemostatic agents. The patient received 12 units of blood transfusion. Her subsequent recovery was uneventful, and she was discharged on the sixth postoperative day. CONCLUSIONS: Unexplained hypotension during laparoscopic liver resection and the application of the Pringle maneuver should raise suspicion of splenic hemorrhage and prompt a timely and adequate intervention.