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LT has become the treatment of choice for children with end-stage liver disease. The scarcity of donors and the considerable mortality on waiting lists have propelled the related living-donor techniques, especially in small children. This population need smaller and good quality grafts and are usually candidates to receive a LLS from a related donor. Many times this grafts are still large and do not fit in the receptor's abdomen, so a further hyper-reduction may be required. Despite all advances in LT field, vascular complications still occur in a considerable proportion remaining as a significant cause of morbidity, graft loss, and mortality. Technical issues currently play an essential role in its genesis. The widely spread technique for biliary and vascular reconstruction in living donor LT (LDLT) nowadays implies removal of the portal vein (PV) clamp after the venous anastomosis, then the arterial reconstruction is done, followed by the biliary reconstruction. However, due to the posterior location of the LLS bile duct, for its reconstruction, a rotation of the liver is required risking a potential transient PV occlusion leading to thrombosis afterward. We describe a new technique that involves performing biliary reconstruction after the PV anastomosis and before removing the vascular clamp, thus allowing to freely rotate the liver with less risk of PV occlusion and thrombosis.

Liver resection combined with colorectal surgery (CRS) is the only curative option in many patients presenting with synchronous colorectal cancer and liver metastases (CRLM). Simultaneous resection has been shown to offer benefits in patients with low hepatic tumor load; however, in the setting of in situ colorectal tumor with extensive CRLM and a small predicted future liver remnant (FLR), the use of simultaneous ALPPS and CRS is controversial, lacking outcome data. Thirty-one cases of simultaneous ALPPS and CRS prospectively entered into the International ALPPS Registry were examined. Univariate analysis was used to identify factors associated with 90-day mortality after stage-2. Thirty patients (97%) completed both stages. CRS was performed during stage-1 in 22 patients (73%). Seven patients (23%) had severe complications (Clavien-Dindo ≥ IIIb) following stage-2 ALPPS. The 90-day mortality rate was 15%. Patients who had a severe complication after stage-1 were significantly more likely to have 90-day mortality following stage-2 (p = 0.002). MELD score > 10 on postoperative day-5 after stage-1 was also significantly associated with 90-day mortality (p = 0.011). Disease-free survival and overall survival were 36% and 76% at 1 year, respectively. In light of the high mortality and poor long-term survival identified in this series, the adoption of ALPPS with CRS cannot be recommended without further data. Patients who suffer severe complications or have an elevated MELD score after stage-1 are at higher risk of mortality following stage-2.

The current associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach is represented by an aggressive first surgical procedure followed by a shorter and less aggressive second procedure. This paradigm has been associated with high morbidity and mortality. Inverting the aggressiveness of the surgical stages might be beneficial in order to facilitate patient recovery during interval period. We propose a new technical paradigm for the ALPPS approach. During the first stage, partial parenchymal transection combined with intraoperative portal vein embolization (PVE) was performed. Liver mobilization was kept at minimum while hilar plate or hilum dissection was strictly avoided. The completion surgery by means of the anterior approach was carried out once sufficient future liver remnant (FLR) hypertrophy and function were certified. We applied this technique in four patients (hepatocellular carcinoma in a cirrhotic liver = 1 and colorectal liver metastases = 3). The mean FLR hypertrophy was 62.6 % (range 49–79). All the four patients underwent the completion surgery with R0 margins, and neither one developed liver failure nor major complications. The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage. The combination of evidence-based facts such as partial parenchymal transection, intraoperative PVE, and “non-touch” oncological rules was feasible and safe, allowing complete tumor resection in highly selected candidates with extensive liver disease.

Backgrounds/aims Metastasis in the pancreatic gland is infrequent, representing between 2-5% of the tumors that affect this organ. However, secondary lesions of clear cell renal carcinoma (CCRC) can occur mainly in this location and it is frequently the only site of dissemination. Treatment of choice is resection in surgically fit patients, as it has been shown that it improves the quality of life and prognosis substantially. We retrospectively reviewed the clinical data of patients with pancreatic resections for metastatic CCRC since there are no reports of the treatment modality of this singular entity in Argentina. Methods Retrospective cohort analysis over a 10-year period including eight patients who underwent pancreatic resection for metastatic CCRC. Results 75% of patients were male with an average age of 65.5 years. The pancreatic surgery occurred at a median time of 9.2 years (1-24.8) from the renal operation. The pancreatic lesions were mostly solitary and asymptomatic. A pancreaticoduodenectomy (PD) was performed in 4 patients (50%). Distal pancreatectomy (DP) was performed in 3 patients (37.3%) and one patient (12.5%) underwent a total pancreaticoduodenectomy. All the patients presented a confirmatory biopsy of pancreatic metastasis of CCRC. Complications were recorded in 3 patients (42.85%). No intraoperative or postoperative mortality was registered. With a median follow-up of 45 months, three patients presented recurrence at 32, 46 and 51 months, respectively. Only one patient showed death due to recurrence at 7.8 month. Conclusions CCRC pancreatic metastases treated surgically have a low morbidity and mortality rate in high volume centers, showing excellent long-term survival.

Objective To evaluate the use of the caudal vena cava collapsibility index (CVCCI) as a predictor of fluid responsiveness in hospitalized, critically ill dogs with hemodynamic or tissue perfusion abnormalities. Design Retrospective observational study. Setting Private referral center. Animals Twenty-seven critically ill, spontaneously breathing dogs with compromised hemodynamics or tissue hypoperfusion. Interventions None. Measurements and main results The electronic medical records were searched for dogs admitted for any cause, from August 2016 to December 2017. We included dogs with ultrasound measurements of: CVCCI, performed at baseline; and velocity time integral (VTI) of the subaortic blood flow, carried out before and after a fluid load. CVCCI was estimated as: (maximum diameter-minimum diameter/maximum diameter) × 100. Dogs in which VTI increased ≥15% were considered fluid responders. The CVCCI accurately predicted fluid responsiveness with an area under the receiver operating characteristic curve of 0.96 (95% CI, 0.88 to 1.00). The optimal cut-off of CVCCI that better discriminated between fluid responders and nonresponders was 27%, with 100.0% sensitivity and 83.3% specificity. At baseline, fluid responders had lower VTI (5.48 [4.26 to 7.40] vs 10.61 [7.38 to 13.23] cm, P = 0.004) than nonresponders. The basal maximum diameter of the caudal vena cava adjusted to body weight was not different between responders and nonresponders (0.050 [0.030 to 0.100] vs 0.079 [0.067 to 0.140] cm/kg, P = 0.339). The increase in VTI was related to basal CVCCI (R = 0.60, P = 0.001). Bland-Altman analysis showed narrow 95% limits of agreement between measurements of CVCCI and VTI performed by different observers or by the same observer. Conclusions The results of this small cohort study suggest that CVCCI can accurately predict fluid responsiveness in critically ill dogs with perfusion abnormalities. Further research is necessary to extrapolate these results to larger populations of hospitalized dogs.

The initial mortality rates of associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) were high. However, recent data from the International Registry show a continuous reduction of early mortality and major morbidity due to risk adjustment in patient selection and less invasive techniques in stage-1 surgery. During the first ALPPS International Consensus in 2015, we introduced a paradigm inversion of ALPPS, the so-called "Mini-ALPPS."We combined a partial liver partition with a novel technique of laparoscopic-assisted percutaneous cannulation of the inferior mesenteric vein for intraoperative transmesenteric portal vein embolization. We report here for the first time, a case of a successful totally laparoscopic Mini-ALPPS, and describe in detail the technical aspects of this new approach.A 61-year-old man with a 6 cm hepatocellular carcinoma compromising the right glissonian pedicle in a fibrotic liver was treated by an extended right hepatectomy using the laparoscopic Mini-ALPPS approach. The patient had an uneventful first stage and was discharged 3 days after. A CT scan performed on postoperative day 8 showed sufficient future liver remnant volume after a 59% hypertrophy. An extended right hepatectomy was uneventfully completed and the patient was discharged 5 days after surgery. The histopathological analysis indicated advanced F4 liver fibrosis and negative tumor margins.This technical innovation allows avoiding a laparotomy to access the mesenteric venous territory and the risks of liver remnant injuries during percutaneous transhepatic approach. This new alternative may result of great utility not only in ALPPS but also for many different circumstances and scenarios.

Background/Aims: Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations influence survival after hepatectomy for colorectal liver metastases (CRLM). However, their prognostic significance has never been evaluated in patients who undergo Associating Liver Partition and Portal vein occlusion for Staged hepatectomy (ALPPS). Methods: Between June 2011 and March 2016, 26 patients underwent ALPPS for CRLM. Complications were classified according to the Clavien-Dindo classification. Bi- and multivariate cox analyses were performed to evaluate variables potentially associated with survival. Results: Overall, morbidity grade ≥3a and 90-day mortality were 38.5 and 0%, respectively. The median follow-up from the time of discharge was 21.5 months (interquartile range 9.6-35.6). One- and 3-year overall survival (OS) was 83.4 and 48.9%, respectively. Patients with mutated (MT) KRAS had a median OS of 15.3 vs. 38.3 months for those with wild-type (WT) KRAS (p < 0.0001). Median disease-free survival was 7.9, 5.6 vs. 12.3 months for MT and WT KRAS, respectively (p = 0.023). KRAS mutation was found to be an independent risk factor for OS (hazard ratio 7.15, 95% CI 1.50-34.11; p = 0.014). Conclusion: KRAS mutation is an independent predictor of poor survival after ALPPS. This finding will help to optimize patient selection, both avoiding futile surgical indication and maximizing the benefit for patients with extensive disease who are otherwise subjected to high-risk aggressive surgery.

OBJECTIVES: The aim of this study was to identify predictors of 90-day mortality after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS), available after stage-1, either to omit or delay stage-2. BACKGROUND DATA: ALPPS is a two-stage hepatectomy for patients with extensive liver tumors with predicted small liver remnants, which has been criticized for its high mortality rate. Risk factors for mortality are unknown. METHODS: Patients in the International Registry undergoing ALPPS from April 2011 to July 2014 were analyzed. Primary outcome was 90-day mortality. Liver function after stage-1 was assessed using the criteria of the International Study Group for Liver Surgery (ISGLS) after stage-1 among others. A multivariable model was used to identify independent predictors of 90-day mortality. RESULTS: Three hundred twenty patients registered by 55 centers worldwide were evaluated. Overall 90-day mortality was 8.8% (28/320). The predominant cause for 90-day mortality was postoperative liver failure in 75% of patients. Fourteen percent of patients developed liver failure according to ISGLS criteria already after stage-1 ALPPS. Those and patients with a model of end-stage liver disease (MELD) score more than 10 before stage-2 were at significantly higher risk for 90-day mortality after stage-2 with an odds ratio (OR) 3.9 [confidence interval (CI) 1.4-10.9, P = 0.01] and OR 4.9 (CI 1.9-12.7, P = 0.006), respectively. Other factors, such as size of future liver remnant (FLR) before stage-2 and time between stages, were not predictive. CONCLUSIONS: This analysis of the largest cohort of ALPPS patients so far identifies those patients in whom stage-2 ALPPS surgery should be delayed or even denied. These findings may help to make ALPPS safer.

The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) strategy induces rapid future liver remnant (FLR) hypertrophy. Hepatocyte cellular and molecular changes associated with liver hypertrophy during ALPPS remain ill-defined in humans.Patients undergoing the ALPPS approach between June 2011 and October 2014 were extracted. Biopsies from the FLR were obtained during the first and second stages. Hematoxylin-eosin staining and immunohistochemical analysis for expression of the proliferating cell nuclear antigen (PCNA) and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) were performed. The proliferative index was defined as: PCNA-TUNEL ratio.Eleven of 34 patients treated were studied during both stages. Median FLR hypertrophy was 104 % in 6 days, with a mean difference between preoperative and postoperative volume of 361 ml (P 0.001). The mean hepatocyte number increased from 52.7 cells/mm(2) in the first stage to 89.6 cells/mm(2) in the second stage (P = 0.001). PCNA expression increased by 190 % between stages with a linear correlation (r = 0.58) with macroscopic hypertrophy. The proliferative index increased from -3.78 cells/mm(2) in first stage to 2.32 cells/mm(2) in the second stage (P = 0.034).The results of the present study indicate that the rapid FLR volumetric increase observed in ALPPS is accompanied by histological and molecular features of hepatocyte cell proliferation.

To determine the safety, feasibility, and efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in a single high-volume hepatobiliary center.The ALPPS approach allows achieving resectability of liver malignancies by a rapid and large future liver remnant (FLR) hypertrophy. However, this proposal has been associated with high morbidity and mortality rates.This was a single-cohort, prospective, observational study [NCT02164292]. Between June 2011 and April 2014, patients with liver malignancies considered unresectable due to an insufficient FLR who underwent ALPPS were included.Thirty patients were treated. Median age was 58.6 years (range = 35-81) and 19 patients were males (63%). In a median of 6 days (range = 4-67), the median FLR hypertrophy was 89.7% (range = 21-287). Twenty-nine patients completed the second stage (97% feasibility). Morbidity according to the Dindo-Clavien classification was 53% (grade ≥IIIa 43% and grade ≥IIIb 31%). The mortality rate was 6.6%. Total parenchymal transection was identified as an independent risk factor for complications (P = 0.049). There was not significant difference in terms of FLR hypertrophy between total or partial parenchymal transection (P = 0.45). Median hospital stay was 16 days (range = 11-62). The overall and disease-free survival at 1 year was 78% and 67% and at 2 years was 63% and 40%, respectively.This prospective study on the largest reported single-center experience shows that ALPPS has acceptable morbidity and mortality, together with a high oncological feasibility and hypertrophic efficacy. Partial parenchymal transection seems to reduce morbidity without negatively impacting FLR hypertrophy.

Common bile duct injuries (CBDI) are serious complications of cholecystectomies which are often associated with vascular involvement, meaning that their management represents a major challenge to the physician. We present our experience in major hepatectomy due to CBDI, highlighting indications, postoperative complications, and long-term outcomes. From August 1993 to September 2013, 287 patients with CBDI were treated in our centre. In 15 patients of this group (5 %), a major hepatectomy was performed. Eleven patients presented E4 and four presented E5 injuries of Strasberg classification. Seven patients presented vascular involvement. In 12 patients, prior treatment attempts, either biliodigestive anastomosis, endoscopic or percutaneous drainage, was performed without success. The median time delay between lesional surgery and hepatectomy was 24 months. Right hepatectomy was performed in 10 patients and left hepatectomy in 5. Postoperative morbidity was 60 %. The incidence of serious complications (≥grade IIIa of DC classification) was 40 %. There was no mortality in our study. The mean follow-up was 43.5 months and the overall survival was 100 %. Three patients had a single episode of ascendant cholangitis who were successfully treated with medical treatment. All other patients were asymptomatic during follow-up. No patients required further surgical procedures. In our series, major hepatectomy due to CBDI was a successful treatment with high rates of postoperative morbidity and excellent long-term outcomes which require a multidisciplinary approach in referral centres of HPB surgery.

Background: Although several studies relate frailty with poor postoperative outcomes, trials with specific intraabdominal surgery cohorts are scarce.

The management of colorectal liver metastases has evolved over the past decades, with more patients now being offered surgery. The use of modern chemotherapeutic and adjunct techniques to surgery has contributed greatly to improve resectability rates and outcomes. As a consequence, patients with advanced CLM are living longer than they did previously due to these major advances in treatment. The surgical strategy should be tailored according to the existence of both patient and liver-related operative risks. From a technical perspective, the availability of state-of-the-art abdominal imaging is crucial to define resectability and to plan the optimal surgical procedure. Associating an acceptable patient risk with a safe technical proposal and a reasonable oncological indication should be the goal of liver surgeons when selecting candidates for surgery. Patient treatment should be routinely discussed by a multidisciplinary tumor board including colorectal surgeons, liver surgeons, oncologists, radiation oncologists, radiologists, and pathologists. Such a multidisciplinary approach has been demonstrated to offer better patient care and survival outcomes, as well as improved consistency, continuity, coordination, and cost-effectiveness of treatment.

In the last 2 decades, the results of hepatic resections (HR) have significantly improved. This improvement was possible because of the development of new anesthetic techniques, better postoperative care, better patient selection, the development of new technological devices and the specialization of hepatobiliary surgery units. The low mortality in referral centers has extended indication for HRs, allowing surgeons to perform extreme procedures in patients considered unresectable 20 years ago. These extreme procedures include associated vascular resections and reconstruction, ex vivo surgeries and the simultaneous resection of adjacent organs. The incidence of complications and perioperative mortality varies in the literature, between 15–45% and 0–25% respectively. The different criteria used to define morbidity as well as the inclusion (or not) of mild complications (Dindo-Clavien’s Grade 1 and 2) explains in part the variability of morbidity rates in the literature. Different factors have been associated with the development of postoperative complications: blood loss, number of resected segments, preoperative hypoalbuminemia, renal insufficiency, associated biliary procedures, associated vascular procedures, male gender and associated patients comorbidities. In addition, the experience of the surgical team, type of tumor, the moment of indication (elective, urgency, emergency resection), extent of resection, parenchymal quality of the liver (steatosis, steatohepatitis, fibrosis, cirrhosis, post-chemotherapy changes) and patient selection are also key aspects. Reoperations to solve postoperative complications vary between 3 and 19%. The most frequent cause of reoperations is postoperative bleeding and intra-abdominal collections. In this chapter, local specific postoperative complications related to HR are described along with their specific management and prevention.

At diagnosis, 15–25% of patients with stage IV colon cancer have synchronous detected liver metastases. About 30% of patients are not initially resectable due to the extent of hepatic disease or a small future liver remnant (FLR). When size of FLR is regarded to be not sufficient to sustain liver function in the postoperative course, techniques of portal vein occlusion (PVO) such as portal vein embolization (PVE) or portal vein ligation (PVL) can be used in the context of a classic two-stage hepatectomy (TSH) to get increase of the residual liver. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-stage technique which combines PVO and parenchymal transection, followed by hepatectomy in a shorter period of time than classical TSH. However, many concerns have been addressed to the safety of this procedure. Further refinements of the original technique have been explored to improve its results. We report herein the case of a 44-year-old female patient with an obstructive cancer of the sigmoid colon and synchronous bilateral colorectal liver metastases, treated with the so-called “mini-ALPPS” approach.

Background: Portal vein occlusion to increase the size of the future liver remnant (FLR) is well established, using portal vein ligation (PVL) or embolization (PVE) followed by resection 4-8weeks later. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) combines PVL and complete parenchymal transection, followed by hepatectomy within 1-2weeks. ALPPS has been recently introduced but remains controversial. We compare the ability of ALPPS versus PVE or PVL for complete tumor resection. Methods: A retrospective review of all patients undergoing ALPPS or conventional staged hepatectomies using PVL or PVE at four high-volume HPB centres between 2003 and 2012 was performed. Patients with primary liver tumors and liver metastases were included. Primary endpoint was complete tumor resection. Secondary endpoints include 90-day mortality, complications, FLR increase, time to resection, and tumor recurrence. Results: Forty-eight patients with ALPPS were compared with 83 patients with conventional-staged hepatectomies. Eighty-three percent (40/48 patients) of ALPPS patients achieved complete resection compared with 66% (55/83 patients) in PVE/PVL (odds ratio 3.34, p=0.027). Ninety-day mortality in ALPPS and PVE/PVL was 15 and 6%, respectively (p=0.2). Extrapolated growth rate was 11 times higher in ALPPS (34.8cc/day; interquartile range (IQR) 26-49) compared with PVE/PVL (3cc/day; IQR2-6; p=0.001). Tumor recurrence at 1year was 54 versus 52% for ALPPS and PVE/PVL, respectively (p=0.7). Conclusions: This study provides evidence that ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors at the cost of a high mortality. The technique is promising but should currently not be used outside of studies and registries.

BackgroundCommon bile duct injuries (CBDIs) remains a rare but serious complication in children undergoing laparoscopic cholecystectomy (LC), with an incidence of 0.44%. In severe lesions, a major liver resection may be necessary as a definitive treatment. The current principles for safe hepatectomy are mainly focused on the liver parenchyma that remains after resection. Therefore, one of the main factors related to posthepatectomy hepatic insufficiency is the quantity and quality of the future liver remnant (FLR). To achieve an optimal FLR, techniques such as portal vein embolization (PVE) are available.Case presentationWe present the case of a 5-year-old child with a severe CBDI after LC, treated with preoperative PVE followed by a right hepatectomy as definitive treatment. No reports of liver resections and PVE are described in the literature concerning the pediatric population.

Background Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new “ALPPS” approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE. Methods A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed. Results The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection. Conclusion Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.

Liver resection is the treatment of choice for patients with colorectal liver metastases (CRLM). The possibility of achieving curative resection is limited by the future liver remnant (FLR), with posthepatectomy liver failure (PHLF) the most severe possible complication after major liver resection. Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been introduced as a strategy for prevention of PHLF by inducing a rapid and large FLR hypertrophy not achieved by other methods. To date, most of the evidence regarding ALPPS is based on retrospective analysis of small series of patients or of case reports. The promising short-term results obtained are difficult to interpret oncologically, because of the heterogeneous groups of patients with different underlying pathology, variable chemotherapy use, and technical variations applied. Only increased experience and long-term outcomes will better define the utility of this novel method.

Posthepatectomy liver failure is the most severe complication after major hepatectomies and it is associated with an insufficient future liver remnant (FLR). Associating liver partition and portal vein ligation (PVL) has recently been described as a revolutionary strategy to induce a rapid and large FLR volume increase. We aim to describe our surgical technique, patient management, and preliminary results with this new two-stage approach.During the first stage, liver partition and PVL of the diseased hemiliver are performed. The completion surgery is carried out after volumetric studies have demonstrated a sufficient FLR and provided the patient is in good condition. This is usually achieved after 7 days. In the second step, the patient undergoes a completion surgery with right hepatectomy, right trisectionectomy, or left trisectionectomy.Fifteen patients with advanced liver tumors were treated. Nine patients were males and the mean age was 54 years old. The mean difference between the preoperative and postoperative FLR volume was 303 ml (p 0.001), which represented a mean volume increase of 78.4 %. All resections were R0. Morbidity and mortality rates were 53 and 0 %, respectively. The average hospital stay was 19 days.The presented technique was feasible and safe in the hands of experienced hepatobiliary surgeons, with satisfactory short-term results. It induces rapid liver hypertrophy and at the same time it offers the possibility of cure to patients previously declared unresectable.

We had previously described a left lateral segment hyper-reduction technique capable of sizing the graft according to the volume of the abdominal cavity of the recipient.The purpose of our study was to evaluate our 14-year live-donor liver transplantation experience with in situ graft hyper-reduction in children under 10 kg of weight.Between January 1997 and May 2011, we performed 881 liver transplants. Two hundred and seventy-seven (n = 277) involved pediatric recipients, of which 102 (37 %) were from live donors. Thirty-five (n = 35) patients under 10 kg of weight underwent hyper-reduced living donor liver transplants. There were 21 females (60 %) and 14 males (40 %), with a median age of 12 months (range 3-23) and a median weight of 7.7 kg (range 5.6-10).Median operative time was 350 min (range 180-510). Median cold ischemia time was 180 min (range 60-300). Twenty-six (n = 26) patients required intraoperative transfusion of blood products. There were 49 postoperative complications involving 26 patients (74 % morbidity rate). One-, 3-, and 5-year survival rates were 87, 79, and 74 %, respectively. Twenty-eight patients are currently alive.Hyper-reduced grafts provide an alternative approach for low-weight pediatric recipients. The relatively high immediate postoperative morbidity could be related to the complexity of these patients.

Surgical resection is the best option for prolonged survival in patients with primary or secondary liver tumors. A sufficient future liver remnant (FLR) volume is needed to prevent post-hepatectomy liver failure (PHLF). With the aim of increasing FLR, a new two-step technique has been recently developed. Our aim is to report our initial experience with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. Analysis was conducted of ten patients previously considered locally unresectable because of small FLR. During first surgical step liver parenchymal partition and portal vein ligation was performed. Seven days after the first procedure, once volumetric and functional studies have demonstrated an appropriate FLR volume, the resection of the deportalized hemiliver was achieved. This technique was successfully performed in all ten patients (feasibility 100 %). Six were male with mean age of 55.2 years (range 39-77). Mean preoperative FLR volume and FLR/total liver volume were 408.4 ml and 27.8 %. Mean postoperative FLR volume was 733 ml representing a mean volume increase of 325 ml or 82 % (range 31-140) (p < 0.0001). All resections were R0 (4 right hepatectomies, 5 right trisectionectomies and 1 left trisectionectomy). There were two grade A post-hepatectomy liver failures. Morbidity was 40 % and mortality 0 %. With a mean follow-up of 187 days, disease-free survival and overall survival were 80 and 100 %, respectively. ALPPS induces a great and fast FLR hypertrophy allowing R0 resections in patients otherwise considered unresectable because of small FLR volume, without severe PHLF and low mortality in experience centers. Further experience is needed to determine long-term outcomes.

BackgroundEn-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure.MethodsThe authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed.ResultsIn both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months.ConclusionsThis new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.

Caroli's disease (CD) management is still controversial. The purpose of this study is to report the most frequent clinical features, treatment options, and outcome obtained after surgical management of CD. A voluntary survey was conducted. Demographic, clinical, surgical, and pathological variables were analyzed. Six centers included 24 patients having received surgical treatment from 1991 to 2009. Seventeen (70.8%) patients were female, with average age of 48.7 years old (20–71), and 95.5% were symptomatic. There was left hemiliver involvement in 75% of the patients. Surgical procedures included nine left lateral sectionectomies, eight left hepatectomies, and four right hepatectomies for those with hemiliver disease, while for patients with bilateral disease, one right hepatectomy and two Roux-en-Y hepaticojejunostomies were performed. The average length of hospitalization was 7 days. For perioperative complications (25%), three patients presented minor complications (types 1–2), while major complications occurred in three patients (type 3a). No mortality was reported. After a median follow-up of 166 months, all patients are alive and free of symptoms. CD diagnosis was confirmed by histology. Congenital hepatic fibrosis was present in two patients (8.3%) and cholangiocarcinoma in one (4.2%). CD in Argentina is more common in females with left hemiliver involvement. Surgical resection is the best curative option in unilateral disease, providing long-term survival free of symptoms and complications. In selected cases of bilateral disease without parenchymal involvement, hepaticojejunostomy should be proposed. However, a close follow-up is mandatory because patients might progress and a transplant should be indicated.

Resumen Introduccion La presentacion, el tratamiento y el pronostico del hepatocarcinoma dependen de la presencia o la ausencia de cirrosis. Existen pocos estudios de hepatocarcinoma en pacientes sin cirrosis. Objetivo Analizar una serie consecutiva de pacientes operados por hepatocarcinoma en higado no cirrotico e identificar los factores de pronostico de la recidiva y la supervivencia. Material y metodo Se opero a 51 pacientes entre 1990 y 2006. Se organizo una base de datos retrospectiva hasta el ano 2001 y prospectiva desde esa fecha. Se evaluaron los resultados de la cirugia. Se realizaron analisis univariado y multivariado para identificar los factores asociados con la supervivencia y el tiempo libre de enfermedad. Resultados Treinta y tres pacientes eran de sexo masculino (mediana de edad de 49,8 anos). Al 72,5% se le realizo una hepatectomia mayor. La mortalidad intrahospitalaria fue del 0% y la morbilidad del 43%. El tiempo de supervivencia fue del 90, el 75 y el 67% a uno, a 2 y a 3 anos. El tiempo libre de enfermedad fue del 65, el 41 y el 37% a uno, a 2 y a 3 anos. En el analisis univariado, la invasion vascular y la infiltracion ganglionar fueron estadisticamente significativas para la supervivencia, pero ninguno de estas fue significativa en el estudio multivariado. Conclusiones La reseccion hepatica mayor es un tratamiento seguro para el tratamiento del hepatocarcinoma en el higado no cirrotico. Tanto la presencia de invasion vascular como la infiltracion ganglionar estan estadisticamente relacionadas con la supervivencia, pero no se identificaron como factores pronosticos independientes de esta.

Liver resection is the treatment of choice and a hope for cure for patients with malignant liver tumors. Resection is many times limited by the amount of future liver remnant, with liver failure being the most severe complication after major resections. To minimize this risk and expand resectability, portal vein occlusion of the tumorbearing lobe is used to redistribute portal flow and induce hypertrophy of contralateral healthy parenchyma. Right portal vein embolization (PVE) is best used before surgery when the future liver remnant is tumor free, while portal vein ligation (PVL) is usually applied as part of 2-stage procedures for patients with bilobar disease who initially require tumor removal in the liver remnant. Around 20% to 40% hypertrophy can be achieved in 8 to 12 weeks with these strategies. However, up to 40% of patients never arrive to tumor resection either because of disease progression or insufficient hypertrophy during these long interval periods. The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach has emerged as an innovative 2-stage hepatectomy developed in Germany and characterized by a short interval between both surgical procedures. 1 Briefly, during the first stage, the liver parenchyma is divided in 2 hemilivers and PVL of the diseasedhemiliverisperformed.Oncesufficienthypertrophy

Extended liver resections in patients with hepatocellular carcinoma (HCC) are problematic due to hepatitis, fibrosis, and cirrhosis. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been promoted as a novel method to induce hypertrophy for patients with extensive colorectal liver metastases, but outcomes in HCC have not been well investigated.All patients registered in the international ALPPS Registry ( www.alpps.org ) from 2010 to 2015 were studied. Hypertrophy of the future liver remnant, perioperative morbidity and mortality, age, overall survival, and other parameters were compared between patients with HCC and patients with colorectal liver metastases (CRLM).The study compared 35 patients with HCC and 225 patients with CRLM. The majority of patients undergoing ALPPS for HCC fall into the intermediate-stage category of the Barcelona clinic algorithm. In this study, hypertrophy was rapid and extensive for the HCC patients, albeit lower than for the CRLM patients (47 vs. 76 %; p 0.002). Hypertrophy showed a linear negative correlation with the degrees of fibrosis. The 90-day mortality for ALPPS used to treat HCC was almost fivefold higher than for CRLM (31 vs. 7 %; p 0.001). Multivariate analysis showed that patients older than 61 years had a significantly reduced overall survival (p 0.004).The ALPPS approach induces a considerable hypertrophic response in HCC patients and allows resection of intermediate-stage HCC, albeit at the cost of a 31 % perioperative mortality rate. The use of ALPPS for HCC remains prohibitive for most patients and should be performed only for a highly selected patient population younger than 60 years with low-grade fibrosis.

The role of liver resection (LR) in patients with non-tumoral hepatic disease (NTHD) remains controversial.To analyze the indications and outcomes of liver resections in patients with NTHD.A retrospective analysis in a multicentric data base was performed. Outcome measures were incidence of postoperative cholangitis, infectious and non-infectious complications, hospital stay and overall mortality.One hundred and fourteen patients underwent LR due to NTHD from January 2001 to November 2011. Fourteen patients presented complex bile duct injuries (CBDI), 18 intra-hepatic lithiasis (IL), 32 liver hydatid cysts (LHC), 10 polycystic liver disease (PLD), 19 Caroli's disease (CD) and 21 other NTHD. Forty seven patients underwent a major hepatectomy and 67 a liver segmentectomy or an atypical liver resection. Thirty four patients (29%) presented surgical related complications. There was not intra or post-operative mortality. In long term outcomes, 98 patients (85%) were asymptomatic, 10 presented episodes of intermittent cholangitis that were treated with antibiotics, and 7 underwent another surgical procedure.LR is a radical and effective procedure to treat benign NTHD instead of other surgical or percutaneous procedures, avoiding multiple sessions of treatment and high post procedure complications rates.

Background Liver remnant function limits major liver resections to generally leave patients with ≥2 Couinaud segments. Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) induces extensive hypertrophy and allows surgeons to perform extreme liver resections. Methods The international ALPPS registry (NCT01924741; 2011–2014) was screened for novel resection type with only 1 segment remnant. The anatomy of lesions and indications for ALPPS, operative technique, complications, survival, and recurrence were evaluated. Results Among 333 patients, 12 underwent monosegment ALPPS hepatectomies in 6 centers, all for extensive bilobar colorectal liver metastases. All patients were considered unresectable by conventional means, and all had a response to or no progression after chemotherapy before surgery. In 2 patients, the liver remnant consisted of segment 2, in 2 of segment 3, in 6 of segment 4, and in 2 of segment 6. Median time to proceed to stage 2 was 13 days and median hypertrophy of the liver remnant was 160%. There was no mortality. Four patients experienced liver failure, but all recovered. Complications higher than Dindo-Clavien IIIa occurred in 4 patients with no long-term sequelae. At a median follow-up of 14 months, 6 patients are tumor free and 6 patients have developed recurrent metastatic disease. Conclusion ALPPS allows systematic liver resections with monosegment remnants, a novelty in liver surgery. Because such resections are difficult to conceive without rapid hypertrophy, we propose to name such resections after the segments constituting the liver remnant rather than the segments removed.