Oldhafer Felix, Ringe Kristina I, Timrott Kai, Kleine Moritz, Ramackers Wolf, Cammann Sebastian, Jäger Mark D, Klempnauer Juergen, Bektas Hueseyin, Vondran Florian W R
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany.
Patient Saf Surg. 2016 Jun 10;10:16. doi: 10.1186/s13037-016-0104-y. eCollection 2016.
The two-stage liver resection combining in situ liver transection with portal vein ligation, also referred to as ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy), has been described as a promising method to increase the resectability of liver tumors. However, one of the most important issues regarding the safety of this procedure is the optimal timing of the second stage at the point of sufficient hypertrophy of the future liver remnant. The recently developed liver maximum function capacity test (LiMAx) can be applied to monitor the liver function postoperatively and hence could be a useful tool for decision-making regarding the timing of the second stage of ALPPS.
A 73-year-old female patient presented with metachronous colorectal liver metastasis comprising the complete right liver lobe as well as segment IV. Due to an insufficient future liver remnant (19.3 %; segments II and III of the liver) and a low future liver remnant:body weight ratio (0.28 %) the decision was made to perform an ALPPS-procedure in order to avoid development of postoperative small-for-size syndrome. Despite a formally sufficient increase of the FLR to 30.8 % within 7 days after the first step of ALPPS, the liver function was seen to only slowly increase as expressed by a LiMAx value of 245 μg/h/kg (baseline of 282 μg/h/kg prior to surgery). By means of the LiMAx test, sufficient increase of liver function eventually was detected by postoperative day 11 (LiMAx value of 371 μg/h/kg; FLR 35.2 %) so that the second step of ALPPS (completion of hepatectomy) was performed with no signs of liver failure during further clinical course.
Performing ALPPS we have observed a significant difference between the increase in future liver remnant volume and function applying the LiMAx test. The latter tool thus might proof valuable for application in two-stage liver resection to avoid postoperative small-for-size syndrome.
两阶段肝切除术结合原位肝离断与门静脉结扎术，也称为ALPPS（联合肝脏分割和门静脉结扎的分期肝切除术），已被描述为一种提高肝肿瘤可切除性的有前景的方法。然而，关于该手术安全性的最重要问题之一是在未来肝余体积充分肥大时进行第二阶段手术的最佳时机。最近开发的肝脏最大功能容量测试（LiMAx）可用于术后监测肝功能，因此可能是决定ALPPS第二阶段手术时机的有用工具。
一名73岁女性患者出现异时性结直肠癌肝转移，累及整个右肝叶以及IV段。由于未来肝余体积不足（19.3%；肝脏II段和III段）且未来肝余体积与体重之比低（0.28%），决定进行ALPPS手术以避免术后小肝综合征的发生。尽管在ALPPS第一步术后7天内未来肝余体积正式充分增加至30.8%，但肝功能仅缓慢增加，LiMAx值为245μg/h/kg（术前基线为282μg/h/kg）。通过LiMAx测试，最终在术后第11天检测到肝功能充分增加（LiMAx值为371μg/h/kg；未来肝余体积35.2%），因此进行了ALPPS的第二步（肝切除术完成），在后续临床过程中未出现肝衰竭迹象。
在进行ALPPS时，我们观察到应用LiMAx测试时未来肝余体积增加与功能增加之间存在显著差异。因此，后一种工具可能在两阶段肝切除术中具有重要价值，以避免术后小肝综合征。
