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How we do it: double in situ split for staged mesohepatectomy in patients with advanced gall bladder cancer and marginal future liver remnant

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Abstract

Purpose

Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has increased the rate of liver resections in patients with marginal future liver remnant. We here describe a modified ALPPS procedure with splitting-off the central liver segments for staged mesohepatectomy in patients with advanced gall bladder cancer.

Methods

A double in situ split for ALPPS (DALPPS) is performed with splitting-off the central liver segments (segments 1, 4, 5, and 8). This induces a rapid hypertrophy of the left lateral (segments 2/3) and right posterior sectors (segments 6/7). An intrahepatic right posterior approach during splitting-off the right posterior sector is introduced as a part of this new procedure. This approach facilitates the dissection and ligation of the right anterior branch of the portal vein (segments 5 and 8) while the liver hilum remains untouched during the first step of surgery.

Results

Two patients with advanced gall bladder cancer were treated with the DALPPS procedure till date. After a short interval (7–9 days), a rapid hypertrophy of the left lateral and right posterior sector was observed (hypertrophy up to 72.6 and 54.6 %, respectively). A staged mesohepatectomy including caudate lobectomy and resection of the extrahepatic bile duct was then performed safely. There was no surgical-technical morbidity. No signs of posthepatectomy liver failure according to the 50-50 criteria were seen. However, one patient died from severe ARDS attributed to the preoperative chemotherapy. Nevertheless, this complication is deemed to be surgery related.

Conclusions

The DALPPS procedure is a new surgical technique for staged mesohepatectomy for patients with small future liver remnant in size or in function. However, appropriate patient selection is mandatory to avoid morbidity and mortality.

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Authors’ contributions

Study conception and design: Tung Yu Tsui

Acquisition of data: Tung Yu Tsui, Asmus Heumann, and Yogesh Vashist

Analysis and interpretation of data: Tung Yu Tsui, Asmus Heumann, and Yogesh Vashist

Drafting of manuscript: Asmus Heumann

Critical revision of manuscript: Tung Yu Tsui, Jakob R. Izbicki, and Yogesh K. Vashist

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Author notes

    Authors and Affiliations

    1. Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

      Tung Yu Tsui, Asmus Heumann, Yogesh K. Vashist & Jakob R. Izbicki

    2. Division of Oncologic Surgery, Hepatobiliary and Transplant Surgery, Department of Surgery, University Medical Center Rostock, Rostock, Germany

      Tung Yu Tsui

    3. Department of Surgery, University Medical Center Rostock, Schillingallee 35, Rostock, Germany

      Tung Yu Tsui

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    1. Tung Yu Tsui
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    2. Asmus Heumann
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    3. Yogesh K. Vashist
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    4. Jakob R. Izbicki
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    Corresponding author

    Correspondence to Tung Yu Tsui.

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    The authors declare that they have no conflicts of interest.

    Ethical approval

    All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

    Informed consent

    Informed consent was obtained from all individual participants included in the study.

    Additional information

    Tung Yu Tsui and Asmus Heumann contributed equally to this work.

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    Tsui, T.Y., Heumann, A., Vashist, Y.K. et al. How we do it: double in situ split for staged mesohepatectomy in patients with advanced gall bladder cancer and marginal future liver remnant. Langenbecks Arch Surg 401, 565–571 (2016). https://doi.org/10.1007/s00423-016-1410-7

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    • DOI: https://doi.org/10.1007/s00423-016-1410-7

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