Al Hasan Ibrahim, Tun-Abraham Mauro Enrique, Wanis Kerollos N, Garcia-Ochoa Carlos, Levstik Mark A, Al-Judaibi Bandar, Hernandez-Alejandro Roberto
From the Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ont. (Al Hasan, Tun-Abraham, Garcia-Ochoa, Hernandez-Alejandro); the Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Al-Judaibi); the Division of Transplantation, University of Rochester Medical Center, Rochester, Minn. (Levstik); and the Department of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia (Al-Judaibi).
Can J Surg. 2017 Dec;60(6):408-415. doi: 10.1503/cjs.005817.
Early reports of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) outcomes have been suboptimal. The literature has confirmed that learning curves influence surgical outcomes. We have 54 months of continuous experience performing ALPPS with strict selection criteria. This study aimed to evaluate the impact of the learning curve on ALPPS outcomes.
We retrospectively compared patients who underwent ALPPS between April 2012 and March 2016. Patients were grouped into 2 24-month (early and late) periods. All candidates had a high tumour load requiring staged hepatectomy after chemotherapy response, a predicted future liver remnant (FLR) less than 30% and good performance status.
Thirty-three patients underwent ALPPS during the study period: 16 in the early group (median age 65 yr, mean body mass index [BMI] 27) and 17 in the late group (median age 60 yr, mean BMI 25). Bilobar disease was comparable in both groups (94% v. 88%, > 0.99). Duration of surgery was not statistically different. Intraoperative blood loss and need for transfusion were significantly lower in the late group (200 ± 109 mL v. 100 ± 43 mL, < 0.05). The late group had a higher proportion of monosegment ALPPS (4:1). There were no deaths within 90 days in either cohort. Rates of postoperative complications were not statistically significant between groups. The R0 resection rate was similar. The entire 1-year disease-free and overall survival were 52% and 84%, respectively.
Excellent results can be obtained in innovative complex surgery with careful patient selection and good technical skills. Additionally, the learning curve brought confidence to perform more complex procedures while maintaining good outcomes.
关于联合肝脏分隔和门静脉结扎分期肝切除术（ALPPS）结果的早期报告并不理想。文献证实学习曲线会影响手术结果。我们有54个月严格按照选择标准进行ALPPS手术的连续经验。本研究旨在评估学习曲线对ALPPS结果的影响。
我们回顾性比较了2012年4月至2016年3月期间接受ALPPS手术的患者。患者被分为两个24个月的时期（早期和晚期）。所有候选患者化疗反应后肿瘤负荷高，需要分期肝切除术，预计未来肝残余量（FLR）小于30%，且身体状况良好。
在研究期间，33例患者接受了ALPPS手术：早期组16例（中位年龄65岁，平均体重指数[BMI]27），晚期组17例（中位年龄60岁，平均BMI 25）。两组的双叶病变情况相当（94%对88%，P>0.99）。手术时间无统计学差异。晚期组术中出血量和输血需求显著更低（200±109 mL对100±43 mL，P<0.05）。晚期组单节段ALPPS的比例更高（4:1）。两组在90天内均无死亡病例。两组术后并发症发生率无统计学差异。R0切除率相似。整个1年的无病生存率和总生存率分别为52%和84%。
通过仔细的患者选择和良好的技术技能，在创新性复杂手术中可获得优异结果。此外，学习曲线使术者有信心实施更复杂的手术，同时保持良好的结果。
