全腹腔镜下ALPPS治疗结直肠癌肝转移的安全性和疗效

doi:10.3877/cma.j.issn.2095-3232.2025.05.013

目的

探讨全腹腔镜下ALPPS治疗结直肠癌肝转移（CRLM）围手术期的安全性及疗效。

方法

回顾性分析2021年4月至2024年4月在中山大学附属第六医院收治的12例全腹腔镜下ALPPS治疗CRLM患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男7例，女5例；年龄 40~70岁，中位年龄56岁。同时性肝转移11例，异时性肝转移1例；肝转移瘤同时分布在肝左、右两叶5例，局限分布在肝右叶5例，同时分布在肝左右叶及尾状叶2例；肝转移瘤最大径为6.5 cm。观察患者围手术期出血量、并发症及恢复情况等。

结果

12例全腹腔镜下ALPPS手术患者中，肝肠病灶同期手术1例，分期手术11例。ALPPS一期和二期手术后，转氨酶均在术后第1~2 d达到高峰，随后逐渐下降；TB在两期术后均未明显升高，均在正常值2倍以内。腹腔镜ALPPS 一期术中出血量中位数为100（50~600） ml；术后并发症2例，1例并发胸腔积液、胆漏，1例并发心功能不全，均为Clavien-Dindo分级Ⅲa级并发症，无手术死亡患者。腹腔镜ALPPS二期术中出血量中位数为125（50~1 000） ml；术后并发症7例，包括胸腔积液、胆漏、伤口愈合不良、心功能不全、黄疸，其中Clavien-Dindo分级Ⅲa级并发症4例，无Ⅲb级及以上并发症，无术后90 d内死亡患者。

结论

全腹腔镜下ALPPS治疗CRLM是安全可行的，为不可切除的CRLM患者提供了根治性手术机会。

关键词: 腹腔镜, 联合肝脏离断和门静脉结扎的分阶段肝切除术, 结直肠癌肝转移

Objective

To evaluate perioperative safety and efficacy of total laparoscopic ALPPS in the treatment of colorectal liver metastasis (CRLM).

Methods

Clinical data of 12 patients with CRLM treated with total laparoscopic ALPPS in the Sixth Affiliated Hospital of Sun Yat-sen University from April 2021 to April 2024 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 7 patients were male and 5 female, aged from 40 to 70 years, with a median age of 56 years. 11 cases were diagnosed with synchronous liver metastases and 1 case of metachronous liver metastasis. 5 patients had liver metastases in left and right lobes, 5 cases in the right lobe, and 2 cases in bilateral lobes and caudate lobe, respectively. The maximum diameter of liver metastases was 6.5 cm. Perioperative bleeding loss, incidence of complications and postoperative recovery were observed.

Results

Among 12 patients undergoing total laparoscopic ALPPS, 1 case received simultaneous resection of liver and intestinal lesions, and 11 cases underwent staged resections. After primary and secondary ALPPS, transaminase levels peaked at postoperative 1-2 d, and then gradually declined. After primary and secondary ALPPS, total bilirubin levels were not significantly increased and maintained within 2 times of normal value. The median amount of bleeding during primary laparoscopic ALPPS was 100 (50-600) ml. 2 patients developed postoperative complications, including 1 case of pleural effusion and biliary fistula and 1 case of cardiac insufficiency, all of which were classified as Clavien-Dindo grade Ⅲa. No patient died after surgery. The median amount of bleeding during secondary laparoscopic ALPPS was 125 (50-1 000) ml. 7 cases suffered from postoperative complications, including pleural effusion, biliary fistula, poor wound healing, cardiac insufficiency and jaundice. 4 patients had Clavien-Dindo grade Ⅲa complications, and no Clavien-Dindo grade Ⅲb or above complications were reported. No patient died within postoperative 90 d.

Conclusion

Total laparoscopic ALPPS is a safe and feasible treatment for CRLM, which provides a radical resection opportunity for unresectable CRLM.

Key words: Laparoscopy, Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS), Colorectal liver metastasis

表1 结直肠癌肝转移患者ALPPS 两期手术肝体积、间隔时间及术中出血情况

例序	一期术前FLR/SLV(%)	二期术前FLR/SLV(%)	FLR增长率(%)	两期手术间隔(d)	一期手术出血量(ml)	二期手术出血量(ml)
1	18	35	97	13	100	200
2	36	54	52	14	200	1 000
3	28	33	19	13	50	20
4	29	37	26	15	300	500
5	41	51	25	21	200	50
6	36	54	48	14	50	150
7	36	39	16	14	50	150
8	38	49	27	21	100	50
9	36	53	50	24	50	400
10	25	42	63	17	600	400
11	31	51	62	14	50	50
12	28	41	47	17	200	100

表1 结直肠癌肝转移患者ALPPS 两期手术肝体积、间隔时间及术中出血情况

例序	一期术前FLR/SLV(%)	二期术前FLR/SLV(%)	FLR增长率(%)	两期手术间隔(d)	一期手术出血量(ml)	二期手术出血量(ml)
1	18	35	97	13	100	200
2	36	54	52	14	200	1 000
3	28	33	19	13	50	20
4	29	37	26	15	300	500
5	41	51	25	21	200	50
6	36	54	48	14	50	150
7	36	39	16	14	50	150
8	38	49	27	21	100	50
9	36	53	50	24	50	400
10	25	42	63	17	600	400
11	31	51	62	14	50	50
12	28	41	47	17	200	100

[1]	Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2024, 74(3): 229-263. DOI: 10.3322/caac.21834.
[2]	Rezapour S, Hosseinzadeh E, Marofi F, et al. Epigenetic-based therapy for colorectal cancer: prospect and involved mechanisms[J]. J Cell Physiol, 2019, 234(11): 19366-19383. DOI: 10.1002/jcp.28658.
[3]	Wu X, Li J, Zhang Y, et al. Identification of immune cell infiltration landscape for predicting prognosis of colorectal cancer[J]. Gastroenterol Rep, 2023, 11: goad014. DOI: 10.1093/gastro/goad014.
[4]	Tan X, Fang Y, Fan X, et al. Testing region selection and prognostic analysis of MLH1 promoter methylation in colorectal cancer in China[J]. Gastroenterol Rep, 2024, 12: goae011. DOI: 10.1093/gastro/goae011.
[5]	Hasselgren K, Røsok BI, Larsen PN, et al. ALPPS improves survival compared with TSH in patients affected of CRLM: survival analysis from the randomized controlled trial LIGRO[J]. Ann Surg, 2021, 273(3): 442-448. DOI: 10.1097/SLA.0000000000003701.
[6]	Sandström P, Røsok BI, Sparrelid E, et al. ALPPS improves resectability compared with conventional two-stage hepatectomy in patients with advanced colorectal liver metastasis: results from a Scandinavian multicenter randomized controlled trial (LIGRO trial)[J]. Ann Surg, 2018, 267(5): 833-840. DOI: 10.1097/SLA.0000000000002511.
[7]	Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings[J]. Ann Surg, 2012, 255(3): 405-414. DOI: 10.1097/SLA.0b013e31824856f5.
[8]	Alvarez FA, Ardiles V, de Santibañes M, et al. Associating liver partition and portal vein ligation for staged hepatectomy offers high oncological feasibility with adequate patient safety: a prospective study at a single center[J]. Ann Surg, 2015, 261(4): 723-732. DOI: 10.1097/SLA.0000000000001046.
[9]	Bertens KA, Hawel J, Lung K, et al. ALPPS: challenging the concept of unresectability: a systematic review[J]. Int J Surg, 2015, 13: 280-287. DOI: 10.1016/j.ijsu.2014.12.008.
[10]	Schadde E, Raptis DA, Schnitzbauer AA, et al. Prediction of mortality after ALPPS stage-1: an analysis of 320 patients from the internationla ALPPS registry[J]. Ann Surg, 2015, 262(5): 780-785; discussion 785-786. DOI: 10.1097/SLA.0000000000001450.
[11]	Torres OJM, Moraes-Junior JMA, Lima e Lima NC, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): a new approach in liver resections[J]. Arq Bras Cir Dig, 2012, 25(4): 290-292. DOI: 10.1590/s0102-67202012000400015.
[12]	Schadde E, Ardiles V, Robles-Campos R, et al. Early survival and safety of ALPPS: first report of the international ALPPS registry[J]. Ann Surg, 2014, 260(5): 829-836; discussion 836-838. DOI: 10.1097/SLA.0000000000000947.
[13]	Oldhafer KJ, Stavrou GA, van Gulik TM, et al. ALPPS: where do we stand, where do we go? Eight recommendations from the first international expert meeting[J]. Ann Surg, 2016, 263(5): 839-841. DOI: 10.1097/SLA.0000000000001633.
[14]	Shi ZR, Yan LN, Li B, et al. Evaluation of standard liver volume formulae for Chinese adults[J]. World J Gastroenterol, 2009, 15(32): 4062-4066. DOI: 10.3748/wjg.15.4062.
[15]	Wang Z, Peng Y, Hu J, et al. Associating liver partition and portal vein ligation for staged hepatectomy for unresectable hepatitis B virus-related hepatocellular carcinoma: a single center study of 45 patients[J]. Ann Surg, 2020, 271(3): 534-541. DOI: 10.1097/SLA.0000000000002942.
[16]	Hernandez-Alejandro R, Ruffolo LI, Alikhanov R, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure for colorectal liver metastasis[J]. Int J Surg, 2020, 82S: 103-108. DOI: 10.1016/j.ijsu.2020.04.009.
[17]	de Santibañes E, Clavien PA. Playing Play-Doh to prevent postoperative liver failure: the "ALPPS" approach[J]. Ann Surg, 2012, 255(3): 415-417. DOI: 10.1097/SLA.0b013e318248577d.
[18]	Qu C, Qu LL, Zhu CZ, et al. Treatment of primary hepatic neuroendocrine tumors with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): a case report and literature review[J]. Medicine, 2018, 97(37): e12408. DOI: 10.1097/MD.0000000000012408.
[19]	Spampinato MG, Mandalá L, Quarta G, et al. One-stage, totally laparoscopic major hepatectomy and colectomy for colorectal neoplasm with synchronous liver metastasis: safety, feasibility and short-term outcome[J]. Surgery, 2013, 153(6): 861-865. DOI: 10.1016/j.surg.2012.06.007.
[20]	Glantzounis GK, Tokidis E, Basourakos SP, et al. The role of portal vein embolization in the surgical management of primary hepatobiliary cancers. A systematic review[J]. Eur J Surg Oncol, 2017, 43(1): 32-41. DOI: 10.1016/j.ejso.2016.05.026.
[21]	Kawaguchi D, Hiroshima Y, Matsuo K, et al. Parenchymal congestion is important for rapid regeneration of the future liver remnant following the ALPPS procedure[J]. Anticancer Res, 2016, 36(9): 4731-4738. DOI: 10.21873/anticanres.11028.
[22]	Schnitzbauer AA, Schadde E, Linecker M, et al. Indicating ALPPS for colorectal liver metastases: a critical analysis of patients in the international ALPPS registry[J]. Surgery, 2018, 164(3): 387-394. DOI: 10.1016/j.surg.2018.02.026.
[23]	Kwon YJ, Lee KG, Choi D. Clinical implications of advances in liver regeneration[J]. Clin Mol Hepatol, 2015, 21(1): 7-13. DOI: 10.3350/cmh.2015.21.1.7.
[24]	Melandro F, Giovanardi F, Hassan R, et al. Minimally invasive approach in the setting of ALPPS procedure: a systematic review of the literature[J]. J Gastrointest Surg, 2019, 23(9): 1917-1924. DOI: 10.1007/s11605-018-04092-x.
[25]	Machado MAC, Makdissi FF, Surjan RC, et al. Transition from open to laparoscopic ALPPS for patients with very small FLR: the initial experience[J]. HPB, 2017, 19(1): 59-66. DOI: 10.1016/j.hpb.2016.10.004.
[26]	Belli G, Gayet B, Han HS, et al. Laparoscopic left hemihepatectomy a consideration for acceptance as standard of care[J]. Surg Endosc, 2013, 27(8): 2721-2726. DOI: 10.1007/s00464-013-2840-8.
[27]	Petrowsky H, Linecker M, Raptis DA, et al. First long-term oncologic results of the ALPPS procedure in a large cohort of patients with colorectal liver metastases[J]. Ann Surg, 2020, 272(5): 793-800. DOI: 10.1097/SLA.0000000000004330.
[28]	Tanaka K, Matsuo K, Murakami T, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): short-term outcome, functional changes in the future liver remnant, and tumor growth activity[J]. Eur J Surg Oncol, 2015, 41(4): 506-512. DOI: 10.1016/j.ejso.2015.01.031.
[29]	Oldhafer KJ, Donati M, Jenner RM, et al. ALPPS for patients with colorectal liver metastases: effective liver hypertrophy, but early tumor recurrence[J]. World J Surg, 2014, 38(6): 1504-1509. DOI: 10.1007/s00268-013-2401-2.
[30]	Capobianco I, Oldhafer KJ, Fard-Aghaie MH, et al. Development and internal validation of the comprehensive ALPPS preoperative risk assessment (CAPRA) score: is the patient suitable for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)?[J]. Hepatobiliary Surg Nutr, 2022, 11(1): 52-66. DOI: 10.21037/hbsn-21-396.

[1]	孙丕绛, 崔上, 杨永君, 冉超, 王槐志. 腹腔镜下肠系膜上动脉优先入路联合门静脉切除重建扩大清扫胰十二指肠切除术（en-bolc）[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(05): 487-487.
[2]	陈华, 孙备. 我国胰头癌腹腔镜胰十二指肠切除术难点与对策[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(05): 483-486.
[3]	李金洁, 颜迪, 高德山. 改良桥式导管内引流在腹腔镜胰十二指肠切除术中的应用研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(05): 488-491.
[4]	李福荣, 王晔飞, 白治渊, 王海霖, 贺志强, 牛福勇. 两种胰肠吻合方法在腹腔镜胰十二指肠切除术中的对比研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(05): 492-495.
[5]	王小军, 蔡瑜, 安艳新, 刘斌, 冯永安. 完全腹腔镜远端胃癌根治术治疗局部进展期胃癌的临床研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(05): 509-512.
[6]	贾宇浩, 吕坤昱, 刘志强, 李保中. 不同入路腹腔镜辅助下根治性远端胃切除术治疗进展期远端胃癌的临床对比[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(05): 513-516.
[7]	菅锎宇, 常如玉, 王达, 顼倩茹, 蒋麟, 贾宝雷, 邱宇轩, 梁峰. 进展期食管胃结合部癌不同手术方式的近期疗效研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(05): 517-522.
[8]	孔宪诚, 沙粒, 杜磊, 刘岗. 以卫式线引导的保留邓氏筋膜全直肠系膜切除术的临床研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(05): 523-526.
[9]	袁德玺, 徐海霞, 华秀丽, 申青. 适形保肛术对低位直肠癌患者术后肛门功能的影响研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(05): 527-530.
[10]	吴金柱, 王锐, 朱国栋, 蔡卫华. 吲哚菁绿荧光导航腹腔镜肝右前叶切除术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(05): 802-802.
[11]	蒋林哲. 腹腔镜胆囊切除+超细胆道镜经胆囊颈管胆道探查术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(05): 803-803.
[12]	平文俊, 李江涛, 陈国栋. 机器人肝门部胆管癌根治术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(05): 804-804.
[13]	唐玥, 陈家璐, 覃德龙, 李宗龙, 汤朝晖, 全志伟. 腹腔镜肝切除治疗复发性肝癌的焦点与难点问题探讨[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(05): 667-672.
[14]	袁文康, 张冲, 张超. 肝脏外科治疗理念的变迁与技术进步[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(05): 673-679.
[15]	黄洁. 腹腔镜肝后上段切除术中的技术挑战与策略思考[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(05): 680-686.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Safety and efficacy of total laparoscopic ALPPS for colorectal liver metastasis

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Safety and efficacy of total laparoscopic ALPPS for colorectal liver metastasis