Zhang Liang, Yang Zhentao, Zhang Shiyu, Wang Wenchao, Zheng Shusen
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China.
NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China.
Front Oncol. 2020 Aug 21;10:1391. doi: 10.3389/fonc.2020.01391. eCollection 2020.
Pushing the surgical limits for initially unresectable colorectal liver metastases (CRLM) are two approaches for sequential liver resection: two-stage hepatectomy (TSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS). However, the role of each treatment modality remains ill-defined. The present meta-analysis was designed to compare the safety, efficacy, and oncological benefits between ALPPS and TSH in the management of advanced CRLM. A systematic literature search was conducted from online databases through to February 2020. Single-arm synthesis and cumulative meta-analysis were performed. Eight studies were included, providing a total of 409 subjects for analysis (ALPPS: = 161; TSH: = 248). The completions of the second stage of the hepatectomy [98 vs. 78%, odds ratio (OR) 5.75, < 0.001] and R0 resection (66 vs. 37%; OR 4.68; < 0.001) were more frequent in patients receiving ALPPS than in those receiving TSH, and the waiting interval was dramatically shortened in ALPPS (11.6 vs. 45.7 days, weighted mean difference = -35.3 days, < 0.001). Nevertheless, the rate of minor complications was significantly higher in ALPPS (59 vs. 18%, OR 6.5, < 0.001) than in TSH. The two treatments were similar in 90-day mortality (7 vs. 5%, = 0.43), major complications (29 vs. 22%, = 0.08), posthepatectomy liver failure (PHLF; 9 vs. 9%, = 0.3), biliary leakage (11 vs. 14%, = 0.86), length of hospital stay (27.95 vs. 26.88 days, = 0.8), 1-year overall survival (79 vs. 84%, = 0.61), 1-year recurrence (49 vs. 39%, = 0.32), and 1-year disease-free survival (34 vs. 39%, = 0.66). Cumulative meta-analyses indicated chronological stability for the pooled effect sizes of resection rate, 90-day mortality, major complications, and PHLF. Compared with TSH, ALPPS for advanced CRLM resulted in superior surgical efficacy with comparable perioperative mortality rate and short-term oncological outcomes, while this was at the cost of increased perioperative minor complications.
对于最初无法切除的结直肠癌肝转移（CRLM），突破手术极限的两种方法是序贯肝切除：两阶段肝切除术（TSH）和联合肝脏分隔与门静脉结扎分期肝切除术（ALPPS）。然而，每种治疗方式的作用仍不明确。本荟萃分析旨在比较ALPPS和TSH在晚期CRLM治疗中的安全性、有效性和肿瘤学获益。通过在线数据库进行了系统的文献检索，直至2020年2月。进行了单臂合成和累积荟萃分析。纳入了八项研究，共409名受试者进行分析（ALPPS组：n = 161；TSH组：n = 248）。接受ALPPS的患者肝切除第二阶段的完成率[98%对78%，优势比（OR）5.00，P < 0.001]和R0切除率（66%对37%；OR 4.68；P < 0.001）高于接受TSH的患者，并且ALPPS的等待间隔显著缩短（11.6天对45.7天，加权平均差 = -35.3天，P < 0.001）。然而，ALPPS的轻微并发症发生率显著高于TSH（59%对18%，OR 6.5，P < 0.001）。两种治疗在90天死亡率（7%对5%，P = 0.43）、严重并发症（29%对22%，P = 0.08）、肝切除术后肝功能衰竭（PHLF；9%对9%，P = 0.3）、胆漏（11%对14%，P = 0.86）、住院时间（27.95天对26.88天，P = 0.8）、1年总生存率（79%对84%，P = 0.61）、1年复发率（49%对39%，P = 0.32）和1年无病生存率（34%对作39%，P = 0.66）方面相似。累积荟萃分析表明，切除率、90天死亡率、严重并发症和PHLF的合并效应量具有时间稳定性。与TSH相比，ALPPS治疗晚期CRLM可带来更高的手术疗效，围手术期死亡率和短期肿瘤学结局相当，但代价是围手术期轻微并发症增加。
