Successful treatment of gastrosplenic fistula after sleeve gastrectomy.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is one of the most performed bariatric procedures. But it is also associated with serious and potentially life-threatening staple line-related complications, such as stomach leak and bleeding. CASE REPORT: The article describes a case of surgical treatment of an early fistula between the stomach and the spleen 3 weeks after LSG. We have focused our attention on the diagnosis and possible treatment options for this potentially life-threatening complication. CONCLUSION: Efforts to reduce the frequency of leakage after LSG include a number of different measures. It is advisable to have expert knowledge not only in primary bariatric surgery, but also in the management of problems and reoperations in gastrointestinal surgery. An individualized approach and multidisciplinary teamwork are essential for successful therapy.

Incidence of postoperative complications in patients with breast cancer depending on the type of drain.

INTRODUCTION: Postoperative complications in patients with breast cancer delay the initiation of adjuvant therapy, prolong the length of hospitalization and reduce the patients' quality of life. Although their incidence can be influenced by many factors, the connection with the type of drain is insufficiently studied in the literature. The aim of this study was to assess whether there is an association between the use of a different drainage system and the occurrence of postoperative complications. METHODS: The data of 183 patients included in this retrospective study were collected from the information system of the Silesian Hospital in Opava and then statistically analyzed. These patients were divided into two groups according to the type of drain used - a Redon drain (active drainage) was used in 96 patients, and a capillary drain (passive drainage) was used in 87 patients. The incidence of seromas and hematomas, the duration of drainage and the amount of wound drainage were compared between the individual groups. RESULTS: The incidence of postoperative hematomas was 22.92% in the group of patients with the Redon drain, and 10.34% in patients with the capillary drain (p=0.024). The incidence of postoperative seromas was comparable for the Redon drain (39.6%) or the capillary drain (35.6%) (p=0.945). No statistically significant differences were found in the drainage time or the amount of wound drainage. CONCLUSION: A statistically significantly lower incidence of postoperative hematomas was observed when using a capillary drain compared to the use of a Redon drain in patients after breast cancer surgery. The drains were comparable with respect to seroma formation. None of the studied drains was significantly more beneficial in terms of the total drainage time and the total amount of wound drainage. KEY WORDS: breast cancer, postoperative complications, drain, hematoma.

Metastatic potential of T1a and T1b non-small cell lung cancer: analysis in the Czech population.

INTRODUCTION: Lung cancer is the most common cause of cancer death in the Czech Republic, in part due to its significant metastatic potential. The aim of this study was to collect real data on the metastatic potential and clinical characteristics of T1a and T1b lung cancer in the Czech population and to investigate potential factors that would predict an increased risk of lymph node metastasis. METHODS: Prospective-retrospective study conducted at the Department of Surgery of the University Hospital Ostrava during the period from January 1, 2015, to July 31, 2022. The study included patients who underwent lobectomy or bilobectomy for T1a and T1b non-small cell lung carcinoma. RESULTS: Out of a total of 165 patients with T1a and T1b lung carcinoma, 17.6% of patients were confirmed to have metastatic involvement of the lymph nodes (with 9.1% classified as N2 lymph node involvement). The highest percentage of positive lymph nodes was observed in patients with tumors located in the upper left lobe (29.5%) and lower right lobe (23.3%). Adenocarcinoma was the most commonly metastasizing carcinoma, with 21.1% of patients showing positive lymph nodes. Neuroendocrine carcinoma metastasized in 19.4% of cases, while squamous cell carcinoma did so in 6.8% of cases. The cumulative risk of having positive lymph nodes in T1a and T1b adenocarcinoma located in the upper left lobe reached 40.0%, of which the risk of N2 lymph node involvement was 25.0%. CONCLUSION: T1a/b non-small cell lung cancer exhibits significantly lower metastatic potential than T1c tumors and higher. Adenocarcinoma showed a 3-fold higher metastatic potential than squamous cell carcinoma, indicating the need for increased attention in the treatment of lung adenocarcinoma, especially in tumors localized in the upper left lobe, where a cumulative risk of lymph node metastasis of up to 40% was observed.

Detection and clinical significance of circulating tumour cells in patients with colorectal carcinoma.

Circulating tumour cells (CTCs) are tumour cells identified in the peripheral blood of patients with malignant disease. CTCs present a very interesting biomarker with promising potential for use in the treatment management of patients with colorectal cancer. Unlike other tumour biomarkers, CTCs are living tumour cells that carry molecular and biological information about the tumour as a whole and reflect ongoing mutational changes. Detection of CTCs from peripheral blood presents a simple and easily repeatable method of liquid biopsy. However, various techniques of CTC selection and detection render clinical use of CTC as a clinical biomarker difficult. The presence/amount of CTCs correlates very well with prognosis and patients ́ survival. Since CTCs have metastatic potential, knowledge of the effect of different treatment modalities on the amount of CTCs in the blood appears to be very important. It can be expected that a more effective treatment regimen will be associated with a reduction in blood CTC levels, and also with a better prognosis. Conversely, an increase or persistence of CTC levels will be associated with resistance to the applied treatment. Routine use of CTCs in clinical practice is limited predominantly by price and very high variability of available scientific evidence. Recently published studies demonstrated the promising potential of CTCs; however, further research will be required for their routine use in clinical practice.

Allen-Masters syndrome as a cause of status ileus - case report.

INTRODUCTION: Internal hernias are rare and are encountered in a small percentage of cases. The hernia in the broad ligament of uterus (Allen-Masters syndrome) is a unique type of internal hernia which represents only approximately 4% of all internal hernias. CASE REPORT: We present the case of a 39-year-old woman admitted for clinical signs of mechanical bowel obstruction. CT examination revealed a dilated loop of small intestine in the left lower abdomen. The patient underwent laparoscopic surgery with the finding of an incarcerated small bowel loop in the ligamentum latum uteri. Small bowel deliberation and ligament defect suture were performed. CONCLUSION: A defect in the ligamentum latum uteri (Allen-Masters syndrome) is a rare diagnosis, usually discovered as an incidental finding in female patients with ileus. This syndrome may explain the vague problems of many patients whose symptoms include dyspareunia, dysmenorrhea, acute and chronic pelvic pain. Allen-Masters syndrome can be diagnosed and successfully managed by laparoscopic approach.

Laparoscopic repair of perforated peptic ulcer - routine procedure or targeted patient selection?

INTRODUCTION: Peptic ulcer is one of the most common diseases of the proximal gastrointestinal tract. Its complications are relatively common, the most serious one being peptic ulcer perforation with the incidence of about 10 cases per 100,000 population per year and the mortality rate of 10-40%. Surgical suture via laparoscopy or laparotomy is the only treatment option. The aim of the study was to compare the short-term results of laparoscopic and open repair of acute peptic ulcer perforation and evaluate the accuracy of the Boey scoring system in the Czech population. METHODS: Retrospective study conducted at the surgical department of the University Hospital Ostrava. The patients underwent laparoscopic or open repair of perforated peptic ulcer in 2017-2021. RESULTS: The study included 60 patients; laparoscopic repair was performed in 43.3% of the patients, and open repair in 56.7%. Postoperative morbidity was 70.0%, mild complications were reported in 23.3% of the patients, and severe complications in 16.7%. Patients undergoing the laparoscopic repair showed a higher incidence of mild as well as severe complications (26.9% vs 20.6% and 19.2% vs 14.7%) but also a higher incidence of an uncomplicated postoperative course. Overall postoperative mortality was 30.0% (laparoscopy 15.4%, laparotomy 41.2%). The study results confirmed the estimated baseline risk of mortality based on the Boey score. CONCLUSION: Laparoscopic repair may be the procedure of choice for patients with no or low risk factors. Patients undergoing laparoscopy showed a higher incidence of mild and severe complications. The higher mortality of patients after open repair is related to their worse initial clinical condition. Preoperative determination of mortality risk using the Boey score is accurate and appropriate in terms of choosing the surgical approach.

Preoperative non-selective administration of nutritional supplements to patients undergoing elective colorectal resection - standard of perioperative care?

INTRODUCTION: Preoperative nutritional support for oncosurgical patients is recommended to minimize the negative effects of potential malnutrition. Nutritional support is intended to adjust the pathophysiological reactions to surgery, reduce postoperative complications, shorten the length of hospital stay and speed up convalescence. The aim of the present study was to evaluate the effect of preoperative nutritional supplements (ONS oral nutritional supplements) on the physical and nutritional status of patients undergoing elective colorectal resection for cancer and to assess patients self-sufficiency after surgery. METHODS: This was a prospective, randomized, single-center clinical trial designed to assess self-sufficiency and return to normal activities in relation to preoperative ONS in patients undergoing elective colorectal surgery. Patients enrolled in the study were randomized to receive ONS twice daily for 7 days prior to surgery or no ONS. RESULTS: One hundred patients were included in the study. The rate of postoperative complications was comparable; no differences were found in postoperative values of laboratory nutritional parameters (albumin, prealbumin). The length of hospital stay was comparable; the stay in the ICU was shorter in patients taking ONS but the difference was not statistically significant. Differences between the study subgroups regarding muscle weight were not statistically significant. Patient self-sufficiency (assessed using the Barthel index) was comparable in both groups before and after surgery (p=0.717 and p=0.327). CONCLUSION: Non-selective preoperative administration of ONS to all patients undergoing elective colorectal resection does not reduce postoperative morbidity or speed up recovery. Patients self-sufficiency and their physical and nutritional status are not affected by preoperative nutritional support.

Our technique of thoracoscopic first rib resection - case report.

INTRODUCTION: First rib resection is a standard surgical treatment for decompressing the neurovascular structures in thoracic outlet syndrome (TOS). Historically, open approaches were used. In this report, we present technical details of thoracoscopic first rib resection. CASE REPORT: This year, we performed two operations in a row using this mini-invasive technique. Three ports were introduced. The used equipment included a laparoscopic camera (30 degree), endoscopic grasper, harmonic scalpel, long neurosurgical bone punch and a long intervertebral disc rongeur. The first rib was cut, separated and removed under thoracoscopic control. CONCLUSION: Thoracoscopic first rib resection for TOS is a safe and promising technique.

Total mesorectal excision for rectal cancer - laparoscopic versus robotic approach.

INTRODUCTION: The primary goal of this study was to evaluate peroperative and early postoperative results of laparoscopic and robotic surgery for rectal cancer with total mesorectal excision (TME) and with primary anastomosis. METHODS: 404 patients were enrolled in the study, divided in two cohorts and compared retrospectively: a laparoscopic group (n=236) versus a robotic (TME + primary coloanal anastomosis) group (n=168). The evaluated cohorts were comparable in sex, age, BMI, ASA score, distal tumor margin from anal verge and neoadjuvant chemoradiotherapy. More advanced tumor stages were observed in the robotic group (p=0.009). RESULTS: The duration of robotic resection was significantly longer compared to laparoscopic resection (p.

Fluorescent angiography in colorectal surgery, the influence of augmented reality in the operating room on the anastomotic leakage after low rectal resection.

INTRODUCTION: Near-infrared (NIR) fluorescence angiography (FA) is an augmented reality (AR) technique. When used in the operating room, it allows colorectal surgeons to visualize and evaluate intestinal blood flow in real time, identify lymph nodes, ureters, or peritoneal metastases. Evaluation of perfusion with FA in augmented reality mode has an impact on reducing the ALR (anastomotic leakage rate) in rectal resections. METHODS: Data analysis of patients after minimally invasive surgery (MIS) for middle and lower rectal adenocarcinoma with total mesorectal excision (TME) using fluorescent angiography (FA) with indocyanine green (ICG) (100 patients, 20152019) were subsequently compared with a historical control group (100 patients) operated on for the same diagnosis before the introduction of the FA-ICG method (20122015) using minimally invasive approach (MIS). The patients were operated on consequently at one workplace. RESULTS: In fifteen patients (15%), the resection line was shifted due to insufficient perfusion detected by FA-ICG. The incidence of AL was lower in the group with FA compared to the group without FA (9% vs. 19%, p=0.042, χ test). A retrospective analysis of the group revealed a significant risk factor (RF) for the anastomotic leak, namely diabetes (p=0.036) and, among others, a protective factor, application of the transanal drain (NoCoil) (p=0.032). CONCLUSION: The introduction of new procedures and the use of new technologies, such as the use of the FA method in the AR mode in resections of the rectum with TME for cancer can lead to a reduction in the incidence of anastomotic leakage.

Laparoscopic liver resections - state of art.

Progress had been made in the miniinvasive surgery in the past 30 years. Laparoscopic liver procedures were expanded from limited resections to major resection and complicated procedures. Miniinvasive approach offered better short-time results and similar oncological outcomes compared with open liver surgery. However, it is still challenging to perform some difficult procedures laparoscopically which requires a learning curve and accumulation of experiences in specialized centers.

Right hemicolectomy - from laparoscopic facilitated technique to robotic intracorporeal anastomosis.

Several different operative techniques have been applied in minimally invasive right colectomy. Data reported in literature confirm the advantages of laparoscopic approach, however, there is no sure evidence of which one is the best. The pure laparoscopic technique with intracorporeal anastomosis seems to show some advantages compared to the other laparoscopic and open procedures, although for the price of technical difficulty and a longer operating time.

Negative pressure therapy with the ULTRAVAC instillation in the therapy of infected laparotomies with fascitis temporary results of a prospective randomized study.

INTRODUCTION: Negative pressure wound therapy is a healing modality utilizing continuous or intermittently applied vacuum to the wound bed. Nowadays is available a vacuum system supported by an automated instillation with volumetric control. It`s main therapeutic benefit is the dilution of the exudate, which reduces the viscosity and secures the «delicate¼ necrectomy. METHOD: Presentation of the temporary results of a prospective randomized study comparing the effectiveness of both therapeutic techniques. Entirely 41 patients were enrolled in the study from November 2016 to September 2018. The primary goal of the project is to compare the length of therapy, the number of surgical debridements and evaluation the financial costs. Secondary targets are observed changes in biological load and bacterial spectrum. RESULTS: The duration of the therapy was 2 days shorter in the experimental group compared to the control sample. However, the average number of applications was higher. Defects with the instillation system were characterized by a shorter cleaning phase (p=0.057). The secondary suture was reached in the experimental group at 84.2% and in the control group at 72.7%. The differences in these parameters were not statistically significant. Fascial disruption was observed in the trial group in 2 patients. The financial costs of the material used was significantly higher in patients with irrigation system (p.

[Intra-operative fluorescence angiography of colorectal anastomotic perfusion: a technical aspects]. / Technické aspekty fluorescencní angiografie pro peroperacní hodnocení perfuze anastomózy v kolorektální chirurgii.

INTRODUCTION: Anastomotic leak after colorectal surgery is a serious complication. Tissue perfusion plays a key role for anastomotic healing. Fluorescence angiography with indocyanine green under near-infrared excitation allows a real-time perfusion assessment. The aim of this study was to evaluate the feasibility and the potential benefit of intraoperative assessment of anastomotic perfusion in colorectal surgery using indocyanine green-enhanced fluorescence in near-infrared light. METHODS: 53 patients with primary anastomosis after elective colon or rectum resection were enrolled between 1 January 2016 and 31 January 2017. Near-infrared fluorescence angiography with indocyanine green was performed to assess tissue perfusion. The data of patient characteristics, data of surgery, data related to perioperative fluorescence angiography and postoperative complications were collected prospectively. RESULTS: Intraoperative fluorescence angiography was successful in 52 patients (98%). There were no adverse effects related to procedure. The mean time from indocyanine green application to visible fluorescence was 35 seconds, the mean added procedure time was 5 minutes. The best contrast was achieved by reducing the dose to 0.1 mg/kg. In 5 patients (9%), fluorescence angiography resulted in a change of the surgical plan. In two cases, the resection line was moved proximally, in two cases the anastomosis was corrected and in one case perfect perfusion of the anastomosis contributed to the decision to abandon the planned protective ileostomy. There was no postoperative anastomotic leak. CONCLUSIONS: Perioperative assessment of anastomotic perfusion in colorectal surgery by use of indocyanine green in near-infrared light is technically feasible with the potential to alter surgical strategy (including avoidance of defunctioning stoma) and to reduce the anastomotic leak rate.Key words: anastomotic leak colorectal surgery fluorescence angiography indocyanine green.

Does laparoscopic intracorporeal ileocolic anastomosis decreases surgical site infection rate? A propensity score-matched cohort study.

AIM: Foreshortened mesentery or thick abdominal wall constitutes a rationale for laparoscopic intracorporeal ileocolic anastomoses (ICA). The aim of this study was to compare intracorporeal to extracorporeal ICA in terms of surgical site infections in patients with Crohn's ileitis and overweight patients with right colon tumors. METHOD: This was a prospective propensity score-matched cohort study enrolling consecutive patients with Crohn's terminal ileitis and overweight patients with right colon tumors undergoing elective laparoscopic right colon resection with intracorporeal or extracorporeal ICA. Propensity score matching with a 1:1 ratio was employed to compare diagnosis-matched patients for age, BMI, ASA, and previous abdominal surgery. RESULTS: Overall, 453 patients were enrolled: 233 intracorporeal vs. 220 extracorporeal. Propensity score matching left 195 intracorporeal and 195 extracorporeal patients comparable for age (p = 0.294), gender (p = 0.683), ASA (p = 0.545), BMI (p = 0.079), previous abdominal surgery (p = 0.348), and diagnosis (p = 0.301). Conversion rates (5.1 vs. 3.6%; p = 0.457) and intraoperative complications (1 vs. 2.1%; p = 0.45) were similar. Overall morbidity (5.1 vs. 12.8%; p = 0.008) and re-intervention rates (3.1 vs. 8.7%; p = 0.029) were significantly higher in extracorporeal patients. Anastomotic leak rates (0.5 vs. 1.5%; p = 0.623) did not differ. Incisional SSI rate was significantly higher in extracorporeal patients (p = 0.01). CONCLUSION: Laparoscopic intracorporeal ICA reduced incisional SSI rates as compared to its extracorporeal counterpart.

[Colorectal cancer in senior patients - are we doing it well?] / Kolorektální karcinom u senioru - deláme to dobre?

INTRODUCTION: Geriatric patients form a significant part of patients with colorectal cancer and their numbers will probably continue to increase. Analysis of the quality of care provided to seniors and the results from their treatment are currently gaining more attention. The aim of this study was to compare how often standard oncological therapy is administered to seniors with colorectal cancer and to compare their results with younger patients along with complications of the therapy. METHOD: A retrospective analysis of data from 170 patients with the diagnosis of colorectal cancer undergoing an elective curative surgical procedure in 2014 and 2015 was performed. Patients were divided into three groups according to their age (<60 years old, 6079 years old, 80 years old). We compared their ASA score, tumor stage (IIV), tumor localization (colon, rectum), incidence of serious complications grade 35 on the Clavien-Dindo scale and adherence to standard oncological treatment in the individual age groups. RESULTS: Patients 80 years and older had significantly higher ASA scores (p=0.0001) and significantly higher stages of tumors according to TNM-7 classification (p=0.0413) in comparison to younger patients. Differences in numbers of serious complications (<60 years - 14%, 6079 years - 13%, 80 years 30%, p=0.1499) did not reach statistical significance. Seniors underwent modified oncological treatment (<60 years - 6%, 6079 years - 9%, 80 years 30%, p = 0.0095) significantly more frequently in comparison to younger age groups. CONCLUSION: The application of standard multimodal oncological treatment is possible even in selected patients that are 80 years and older. Implementation of more reliable methods to objectively predict postoperative complications can become a tool to modify the treatment and improve the results of surgical care in elderly patients.Key words: geriatric patients - oncosurgery complex geriatric assessment colorectal cancer.

[Cholecystostomy--an obsolete or relevant treatment?]. / Cholecystostomie--obsoletní, nebo aktuální resení?

INTRODUCTION: Percutaneous cholecystostomy is considered to be an emergency treatment option when conservative treatment of acute cholecystitis fails in elderly and critically ill patients. The question is: to what extent is this technique still up-to-date or obsolete. METHODS: We retrospectively reviewed data of patients who underwent a computer tomography (CT) guided percutaneous cholecystostomy between 1/20101/2015. We analyzed the patient data, the success rate, complications of the procedure, short- and long-term outcomes. RESULTS: 30 patients undergoing CT-guided percutaneous cholecystostomy at the Department of Surgery, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital during the study period were enrolled. The study group included 21 females (70%) and 9 males (30%) with mean age of 78 years (SD±12.3), median 82 years (range 3493 years). Percutaneous cholecystostomy was indicated for patients with severe cholecystitis/empyema of the gallbladder not responding to conservative therapy who were poor candidates for operative cholecystectomy. Of these, 23 patients (77%) were successfully treated with initial percutaneous cholecystostomy whereas 7 patients (23%) experienced treatment failure - one was subsequently successfully treated with repeated percutaneous cholecystostomy and six underwent emergency cholecystectomy. The mean length of stay was 16.5 days (SD±8.2), median 15 days (7-49 days). The total 30-day mortality was 17%, and indication-related mortality was 10%. Three patients (10%) had a recurrence. One patient required repeated percutaneous drainage, the second recovered on conservative treatment and the third patient underwent acute cholecystectomy. Only one patient (3%) underwent delayed laparoscopic cholecystectomy without complications. CONCLUSION: CT guided percutaneous cholecystostomy is a safe and effective therapeutic modality in patients unfit for surgery.

NOD2/CARD15 mutations and the risk of reoperation in patients with Crohns disease.

INTRODUCTION: Three NOD2/CARD15 gene variants (3020insC, R702W, G908R) have been identified as genetic risk factors for Crohns disease patients. However the diagnostic and therapeutic relevance for clinical practice remains limited. The aim of this study was to evaluate the association between these variants, the risk of reoperation and disease phenotype. METHODS: In 76 Crohns disease patients (41 female, 35 male) with a minimum 5 year follow-up, three polymorphisms of the NOD2/CARD15 gene (R702W, G908R, 3020insC) were tested. Detailed clinical and medical history including surgical procedures and reoperations were obtained by reviewing the medical charts and completed prospectively. Association between the need for reoperation, disease phenotypes and gene variants were analyzed. RESULTS: 24 patients (32%) showed at least one NOD2/CARD15 mutation. 25 patients (33%) required reoperation, 51 (67%) represented the control group. The expected trend that patients with NOD2/CARD15 variants have a higher frequency of reoperations was not confirmed to a level of statistical significance (p=0.2688). Two of the four patients (50%) with the 3020insC variant required further surgery. We did not confirm any association between NOD2/CARD15 mutations and age at diagnosis (p=0.4356), behavior (p=0.6610), or localization (p=0.4747) according to the Montreal classification. CONCLUSION: NOD2/CARD15 polymorphisms did not significantly affect the reoperation rate. Homozygosity for the 3020insC variant in the NOD2/CARD15 gene is associated with a high risk of reoperation. NOD2/CARD15 gene variants are not significantly associated with specific disease phenotypes.

[Intraoperative verification of colorectal anastomotic integrity]. / Peroperacní verifikace integrity kolorektální anastomózy.

Early postoperative anastomotic complications have serious clinical implications for the patients morbidity, mortality as well as long-term results. A number of measures can be undertaken to reduce the risk of anastomotic complications, including intraoperative colorectal anastomotic integrity assessment. Methods used to assess anastomotic reliability have gradually developed from basic mechanical techniques, direct visual endoluminal inspection, to microperfusion assessment of perianastomotic tissue. Moderate benefit in terms of reduced postoperative anastomotic complications has been shown with mechanical patency testing and partly with intraoperative endoscopic visualization of colorectal anastomoses. More recently, indocyanine green (ICG) fluorescence imaging methods have emerged as major contributions to anastomotic patency assessment and intraoperative decision making during surgical colorectal procedures including decreased numbers of ileostomies.

[A new strategy in the surgical treatment of multiple liver tumors - ALPPS]. / Nová strategie chirurgické lécby mnohocetného nádorového postizení jater - ALPPS.

INTRODUCTION: This systematic review was performed to introduce the two-staged hepatectomy procedure (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy - ALPPS) and present its current results. MATERIAL AND METHODS: We conducted a systematic literature search using the PubMed database with key words "ALPPS" or "staged liver resection". The inclusion criteria were randomized trials or cohort studies. Case reports were excluded. The primary end-point was the assessment of liver tissue hypertrophy after the ALPPS procedure. Morbidity and mortality evaluation were the secondary end-point. RESULTS: After an electronic data search of PubMed with the selected key words, six cohort studies evaluating 96 patients met the inclusion criteria. There was no prospective randomised trial. Based on the results of the individual studies, liver hypertrophy ranged from 74 to 87%. Morbidity and mortality ranged from 53 to 71% and 0 to 13% respectively. CONCLUSIONS: Despite the higher morbidity and mortality the ALPPS procedure could be a promising technique for a selected group of patients with multiple liver tumors. However long term results are not yet available.