Olthof Pim B, Tomassini Federico, Huespe Pablo E, Truant Stephanie, Pruvot François-René, Troisi Roberto I, Castro Carlos, Schadde Erik, Axelsson Rimma, Sparrelid Ernesto, Bennink Roelof J, Adam Rene, van Gulik Thomas M, de Santibanes Eduardo
Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
Department of General, HPB and Liver Transplantation Surgery, Ghent University Hospital Medical School, Ghent, Belgium.
Surgery. 2017 Oct;162(4):775-783. doi: 10.1016/j.surg.2017.05.022. Epub 2017 Jul 18.
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces a rapid and extensive increase in liver volume. The functional quality of this hypertrophic response has been called into question because ALPPS is associated with a substantial incidence of liver failure and high perioperative mortality. This multicenter study aimed to evaluate functional liver regeneration in contrast to volumetric liver regeneration in ALPPS, using technetium-99m hepatobiliary scintigraphy and computed tomography volumetry, respectively.
Patients who underwent ALPPS and hepatobiliary scintigraphy in 6 centers were included. Hepatobiliary scintigraphy data were analyzed centrally at the Academic Medical Center in Amsterdam according to established protocols. Increase in liver function as measured by hepatobiliary scintigraphy after stage 1 of ALPPS was compared with the increase in liver volume. In addition, we analyzed the impact of liver function and volume on postoperative outcomes including liver failure, morbidity, and mortality.
In 60 patients, future liver remnant volume increased by a median 78% (interquartile range 48-110) during a median 8 (interquartile range 6-14) days after stage 1, while function as measured by hepatobiliary scintigraphy increased by a median 29% (interquartile range 1-55) throughout 7 days (interquartile range 6-10) in the 27 patients with paired measurements. After stage 2 of ALPPS, liver failure occurred in 5/60 (8%) patients, severe complications in 24/60 (40%), and mortality occurred in 4/60 (7%).
In ALPPS, volumetry overestimates liver function as measured by hepatobiliary scintigraphy and may be responsible for the high rate of liver failure. Quantitative liver function tests are highly recommended to avoid post hepatectomy liver failure.
联合肝脏分割和门静脉结扎分期肝切除术（ALPPS）可使肝脏体积迅速且大幅增加。这种肥大反应的功能质量受到质疑，因为ALPPS与肝衰竭的高发生率和围手术期高死亡率相关。这项多中心研究旨在分别使用锝-99m肝胆闪烁显像和计算机断层扫描容积测量法，评估ALPPS中功能性肝再生与肝脏容积性再生的对比情况。
纳入在6个中心接受ALPPS及肝胆闪烁显像的患者。根据既定方案，在阿姆斯特丹学术医疗中心对肝胆闪烁显像数据进行集中分析。将ALPPS第一阶段后通过肝胆闪烁显像测量的肝功能增加情况与肝脏体积增加情况进行比较。此外，我们分析了肝功能和肝脏体积对包括肝衰竭、发病率和死亡率在内的术后结局的影响。
在60例患者中，第一阶段后，未来肝残余体积在中位8天（四分位间距6 - 14天）内中位增加78%（四分位间距48 - 110），而在27例有配对测量的患者中，通过肝胆闪烁显像测量的功能在整个7天（四分位间距6 - 10天）内中位增加29%（四分位间距1 - 55）。ALPPS第二阶段后，5/60（8%）例患者发生肝衰竭，严重并发症发生在24/60（40%）例患者中，4/60（7%）例患者死亡。
在ALPPS中，容积测量法高估了通过肝胆闪烁显像测量的肝功能，这可能是肝衰竭发生率高的原因。强烈建议进行定量肝功能检查以避免肝切除术后肝衰竭。
