Totally laparoscopic associating liver tourniquet and portal vein occlusion for staged hepatectomy combined with simultaneous left hemicolectomy for bilateral liver metastases of the primary colon cancer: A case report.

BACKGROUND: Resection of the liver is often limited to the insufficient future liver remnant (FLR). To address this problem, the modification surgical technique "associating liver tourniquet and portal vein occlusion for staged hepatectomy" (ALTPS) was developed and led to quick hypertrophy in a short interval. In some colorectal cancer patients with multiple and bilobar metastases, the resection of the primary is often protracted immensely to the unpredictable postoperative complications for whom is to be treated with a liver-first approach. To overcome this problem, a simultaneous resection of the primary tumor and totally laparoscopic ALTPS for bilateral liver metastases of the primary colon cancer were performed. CASE
SUMMARY: A 63-year-old female patient with left colon cancer and synchronous bilateral colorectal liver metastases underwent a totally laparoscopic ALTPS and simultaneous left hemicolectomy because of the small FLR. The operative times were 460 minutes for the first stage and 240 minutes for the second stage without the need for blood transfusions. The recoveries after the first and the second operations were uneventful, and the patient was discharged on postoperative day 11 of the second stage operation.
CONCLUSION: Our case shows the totally laparoscopic ALTPS and simultaneous left hemicolectomy at step 1 for bilobar liver metastases of the primary colon cancer with no severe postoperative complications. If a resection of the primary tumor does not compromise the split procedure, the combination of pure laparoscopic ALTPS and primary resection is feasible and safe.

Introduction

Extended hepatectomy is often limited to the insufficient future liver remnant (FLR).[ To address this problem, the modification surgical technique “associating liver tourniquet and portal vein occlusion for staged hepatectomy” (ALTPS) was developed and led to quick hypertrophy in a short interval.[ Although liver resection has proved the only curative modality of colorectal cancer patients with multiple and bilobar liver metastases, the resection of the primary is often protracted immensely to the unpredictable postoperative complications for whom is to be treated with a liver-first approach.[ This situation can be solved with the combination of the first step of ALTPS and simultaneous removal of the primary tumor.[ Recent advances in laparoscopic techniques have increased the indications for laparoscopic liver resection.[ Therefore, a simultaneous resection of the primary tumor and totally laparoscopic ALTPS for bilateral liver metastases of the primary colon cancer were performed.

Case report

A 63-year-old female patient with left colon cancer and synchronous bilateral colorectal liver metastases underwent a totally laparoscopic ALTPS and simultaneous left hemicolectomy.

The total liver volume (TLV) was 1188 mL, and the volume of the left lateral section, the future liver remnant volume (FLRV), was 376 mL (Fig. 1). To achieve sufficient hypertrophy of the left lateral section, the first step of ALTPS plus left hemicolectomy was performed. Informed consent was obtained from the patient and her parents. The West China Hospital administration and the ethics committee authorized the surgery.

Figure 1

Preoperative computed tomography showing the tumor invading the segment VIII, segment IV, and segment III; the FLR is 376 mL. FLR = future liver remnant.

The operation was started with laparoscopic left hemicolectomy. After step 1, laparoscopic resection of partial segment III was followed by identification of the portal structures, and the right portal vein was ligated. The hepatic artery and common bile duct were marked with loops. After it was confirmed that the tumor had not spread and that R0 resection could be achieved at the second stage of the ALTPS by laparoscopic ultrasound, the tourniquet was passed between the middle and left hepatic veins and continued around the base of the left lobe to the left portal vein pedicle. The blood loss in stage 1 was 250 mL. Postoperative pathology showed ulcerative adenocarcinoma of the colon and a low-grade adenocarcinoma of the liver.

Reevaluation of the patient after 13 days showed that the left liver had regenerated. Volumetry of the FLRV was 550 mL and the TLV was 1410 mL (Fig. 2). Considering that the weight of the patient is only 44 kg (standard liver volume [SLV] = 1029 mL), the second step of the laparoscopic ALTPS was performed the following day. Small adhesions were found at laparoscopy. The right hepatic artery and the right bile duct were sectioned, and the right trisectionectomy was performed at the level of the tourniquet. There were no intraoperative complications, and the blood loss was 300 mL. The postoperative pathology revealed a low-grade adenocarcinoma of the liver which is in compliance with colorectal liver metastasis.

Figure 2

Control computed tomography at postoperative day 13 showing the hypertrophy of the left lobe; the FLR rise to 550 mL. FLR = future liver remnant.

The operative times were 460 minutes for the first stage and 240 minutes for the second stage. The recoveries after the first and the second operations were uneventful, and the patient was discharged on postoperative day 11 of the second stage operation with no 90-day postoperative mortality.

Discussion

Hepatectomy may prolong the survival time of colorectal cancer patients with liver metastases.[ However, for patients with bilateral liver metastases, a curative resection either cannot be achieved with a single procedure or would result in a too small FLR.[ To address this problem, 2-stage liver resection with portal vein embolization (PVE) or portal vein ligation was developed to achieve sufficient hypertrophy of the FLR.[ These techniques, however, remain controversial due to the problems of delay or absence of hypertrophy and tumor progression related to the formation of intrahepatic vascular collaterals.[ In 2007, the first case of “associating liver partition and portal vein ligation for staged hepatectomy” (ALPPS) procedure was performed successfully, and since then, this technique was adopted worldwide with reported rapid growth of the FLR in 7 to 14 days and prevention of tumor progression.[ However, ALPPS was associated with a morbidity rate as high as 68% and a mortality rate as high as 14% regarding biliary fistulas, infected collections, and posthepatectomy liver failure.[ Moreover, the first stage of this technique is very aggressive and often associated with prolonged operative duration and high blood loss. Therefore, the modification surgical technique ALTPS was emerged with reduced morbidity and mortality rates. Robles et al[ reported 22 ALTPS procedures with the same regeneration rate and less aggressiveness of both surgical interventions compared to traditional ALPPS. Instead of splitting the liver parenchyma during the first stage of the surgery, ALTPS simply placed a tourniquet in the umbilical fissure or Cantlie line and thereby reduced the aggressiveness of the first intervention. During the second stage of ALTPS, liver parenchyma transection along the tourniquet could be performed quickly with less blood loss and thereby reduced the aggressiveness of the second intervention. In this case of totally laparoscopic ALTPS, few adhesions were encountered and the transection surface shrank induced by the tourniquet which facilitated the parenchyma transection without the use of Pringle maneuver. In the era of laparoscopic surgery, it has been proved that laparoscopic hepatectomy is associated with reduced blood loss, decreased overall and liver-specific complications, shorter postoperative hospital stays, and fewer adhesions which may facilitate second hepatectomy or liver transplantation compared with traditional open liver resection.[ Previous series have reported that the safety and feasibility of laparoscopic ALPPS for primary and secondary cancers of the liver for patients who were once deemed unresectable and laparoscopic ALTPS might provide an even less invasive modification of the traditional open ALPPS procedure.[

It is estimated that there are nearly 25% of colorectal cancer patients have liver metastases at presentation.[ If patients with multiple and bilobar metastases are to be treated with a liver-first approach, the resection of the primary could sometimes be severely protracted due to the unpredictable postoperative complications.[ Although combined resections have been associated with an increase in morbidity and mortality rates compared to the primary-first approach followed by liver resection about 2 months later, recent studies confirmed its feasibility and safety even when major hepatectomies have to be performed.[ Moreover, the simultaneous approach can minimize the use of neoadjuvant chemotherapy, which may in turn potentiate the effects of systemic chemotherapy by reducing the total volume of tumor present.

As a result, we combined the 2 less aggressive approaches and presented the totally laparoscopic ALTPS and simultaneous left hemicolectomy at step 1 for bilateral liver metastases of the primary colon cancer with no severe postoperative complications. If a resection of the primary tumor does not compromise the split procedure, the combination of pure laparoscopic ALTPS and primary resection is feasible and safe.