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.

First Ever Robotic Stage One ALPPS Procedure in India: for Colorectal Liver Metastases.

Twenty five percent of total liver volume (TLV) is considered as the ideal functional liver remnant (FLR) in major liver resections. In patients with macro-vesicular steatosis, early cirrhosis, and post-neoadjuvant chemotherapy (NACT), hepatocellular injury is common. In such instances, up to 40% of FLR may be required. So in cases of marginal FLR, pre-operative portal vein (PV) embolization or two-stage hepatectomy with PV occlusion is used. Both of which take up to 14 weeks between stages and 30% of patients fail to reach the second resection either due to inadequate FLR growth or disease progression. Associated liver partition and portal vein ligation (ALPPS) procedure has become the gold standard for those cases. A 57-year-old male presented with rectosigmoid growth + multiple right liver and segment 4B metastases. Post-NACT MRI showed interval progression of lesions. Preoperative CT (computed tomography) volumetric scan showed a FLR/TLV (future liver remnant/total liver volume) of 22%. Since patient received 10 cycles of NACT, ALPPS procedure was planned ahead of direct liver resection. Robotic ALPPS stage 1 sparing left lateral segment and 4A + anterior resection was done. We transected the parenchyma between the FLR and the diseased part of the liver with concomitant right portal vein ligation done robotically. CT abdomen done on POD7 showed hypertrophied left lateral segment. Second stage was performed on the eighth post-operative day with FLR/TLV increasing to 37%. Robotic ALPPS procedure for stage one is a safe and feasible technique in experienced centers with advanced robotic skills.

Institutional Experience in the Management of Hilar Liver Obstruction- A Series of 13 Cases.

Neoplastic hilar obstruction to the liver outflow presents a unique challenge to the surgeon, wherein, the balance between a curative and possibly larger resection has to be achieved against a more conservative local resection. These are often technically demanding and have thus, far produced equivocal outcomes on both ends. The present case series is on 13 patients who presented with hilar obstruction. They all underwent resections with possible curative intent. The focus of our review is on the technical nuances and the strategies we used, intra- and peri-operatively to make resections possible in these patients, who at first look were deemed inoperable. Among the 13, 10 had hilar cholangiocarcinoma (CCA) while the others had a more benign diagnosis e.g., Hydatid disease. We did not encounter any peri-operative mortality in our series. Two of our patients had to be re-explored for intra-abdominal complications. Among the 13, we encountered two deaths. The rest of the patients are still on follow-up as of April 2016. Hilar CCA continue to be rare and challenging tumours for the Hepato Pancreato Biliary (HPB) surgeon to manage. Outlooks are currently changing as we try to resect bigger and more complicated hilar liver tumours with better results.

Can we direct organ allocation based on predicted outcome? Hepatocellular carcinoma outside of UCSF criteria or retransplant?

BACKGROUND: In this study, we ask between patients with graft failure listed for retransplant and patients with hepatocellular carcinoma (HCC) outside of UCSF criteria, who has the greater survival benefit with transplantation? METHODS: This is a retrospective analysis, of liver transplant (LT) patients, done between February 2002 and December 2009 at our center. Patients were included in the "extended HCC" group if their tumor was pathologically beyond UCSF criteria at LT and in the "redo" group if they underwent LT for graft failure occurring more than 3 months after the initial LT. Extended criteria donors (ECDs) were defined as donors above 70 years old, DCD, serology positive for HCV, and split grafts. RESULTS: There were 25 redos and 37 extended HCC patients. Use of ECDs or high donor risk index organs was associated with poor outcome in both groups (P = 0.005). Overall, the extended HCC population had a much better survival than redos, both at 1 and 3 years. CONCLUSION: These two very different but high risk patient populations have very different survival rates. At a time where regulatory agencies demand more and more with regards to transplant outcomes, we think the transplant community has to reflect on whether allocation justice and fair access to transplant are respected if we start allocating organs based on outcomes.

Cystogram with dumbbell shaped urinary bladder in a sliding inguinal hernia.

Sliding inguinal hernias present with various symptoms and these are usually direct inguinal hernias containing various abdominal viscera. Case reports and series have been published with various organs and rare organs being part of the hernia. Urinary bladder is a known content of sliding hernias. This case report emphasizes this aspect in a picturesque manner and the importance of radiological investigations for pre-surgical evaluation.