University Hospital Frankfurt, Goethe-University Frankfurt/Main, Clinic for General and Visceral Surgery, Germany.
Rush University Medical Center, Department of Transplant Surgery, Department of Surgery, Chicago, IL, USA.
Surgery. 2018 Sep;164(3):387-394. doi: 10.1016/j.surg.2018.02.026. Epub 2018 May 24.
In the international associating liver partition and portal vein ligation for staged hepatectomy registry, more than 50% of patients underwent associating liver partition and portal vein ligation for staged hepatectomy with a right hepatectomy. This study evaluated the necessity of two-stage hepatectomies being performed as right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy in patients with colorectal liver metastases versus right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy.
All patients registered between 2012 and 2017 undergoing associating liver partition and portal vein ligation for staged hepatectomy for colorectal liver metastases were included. A liver to body weight index of 0.5 or less prior to stage I in the presence of liver damage was used as an internationally accepted standard to justify a two-stage hepatectomy.
Four-hundred and three patients with colorectal liver metastases with right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy (n = 183) or right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy (n = 220) were analyzed. Presence of metastases in segments II/III, liver damage, number of patients on chemotherapy, and cycles were comparable, and there was a comparable response to chemotherapy. Liver to body weight index was different prior to stage 1 (right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy: 0.33 ± 0.12 versus right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy: 0.40 ± 0,14; P < .001) and prior to stage 2 (right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy: 0.58 ± 0.17 versus right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy: 0.66 ± 0,18; P < .001). Hypertrophy rates were similar between groups. As much as 16.9% and 7.2% of patients in right hepatectomy associating liver partition and portal vein ligation for staged hepatectomy and right trisectionectomy associating liver partition and portal vein ligation for staged hepatectomy had no apparent justification for a two-stage hepatectomy based on LBWI prior to stage 1 and absence of chemotherapy (<12 cycles).
More than 15% of associating liver partition and portal vein ligation for staged hepatectomy procedures were performed in patients who may have had no indication for a two-stage hepatectomy, especially in the group of patients with right hepatectomy. Thus, it appears that there is a risk of the overuse of associating liver partition and portal vein ligation for staged hepatectomy because of its great potential to induce volume growth. Due to the high perioperative risk of associating liver partition and portal vein ligation for staged hepatectomy, indications should be carefully reconsidered.
在国际联合肝脏分割和门静脉结扎分期肝切除术注册中心，超过 50%的患者接受了联合肝脏分割和门静脉结扎分期肝切除术，其中包括右半肝切除术。本研究评估了在结直肠癌肝转移患者中，与右三叶切除术联合肝脏分割和门静脉结扎分期肝切除术相比，右半肝切除术联合肝脏分割和门静脉结扎分期肝切除术是否需要进行两阶段肝切除术。
纳入 2012 年至 2017 年间接受联合肝脏分割和门静脉结扎分期肝切除术治疗结直肠癌肝转移的所有患者。在第一阶段前，肝损伤患者的肝体比指数（liver to body weight index，LBWI）小于 0.5 被认为是进行两阶段肝切除术的国际公认标准。
共分析了 403 例接受右半肝切除术联合肝脏分割和门静脉结扎分期肝切除术（n=183）或右三叶切除术联合肝脏分割和门静脉结扎分期肝切除术（n=220）的结直肠癌肝转移患者。在存在肝转移的 II/III 段、肝损伤、接受化疗的患者数量和化疗周期方面，两组无显著差异，且对化疗的反应也相似。但第一阶段前（右三叶切除术联合肝脏分割和门静脉结扎分期肝切除术：0.33±0.12 比右半肝切除术联合肝脏分割和门静脉结扎分期肝切除术：0.40±0.14；P<0.001）和第二阶段前（右三叶切除术联合肝脏分割和门静脉结扎分期肝切除术：0.58±0.17 比右半肝切除术联合肝脏分割和门静脉结扎分期肝切除术：0.66±0.18；P<0.001）的 LBWI 存在差异。两组的肝增生率相似。在右半肝切除术联合肝脏分割和门静脉结扎分期肝切除术和右三叶切除术联合肝脏分割和门静脉结扎分期肝切除术患者中，分别有 16.9%和 7.2%的患者基于第一阶段前的 LBWI 和缺乏化疗（<12 个周期），似乎没有理由进行两阶段肝切除术。
在接受联合肝脏分割和门静脉结扎分期肝切除术的患者中，超过 15%的患者可能没有进行两阶段肝切除术的指征，尤其是在接受右半肝切除术的患者中。因此，由于联合肝脏分割和门静脉结扎分期肝切除术具有巨大的诱导体积增长的潜力，该术式可能被过度使用。由于联合肝脏分割和门静脉结扎分期肝切除术的围手术期风险较高，应仔细重新考虑其适应证。
