Liver transplantation for unresectable colorectal liver metastases (CRLM) using extended criteria donor (ECD) grafts: proceed with caution

Liver transplantation(LT)for colorectal liver metastases(CRLM)seems to be nowadays an established treatment,not only of unresectable CRLM(uCRLM)(1)but also for borderline resectable ones(2,3).For these patients,the benefit of LT vs standard modern advanced palliative therapies ranges between 40-80%(1).Notwithstanding the high rates of recurrence,LT can definitely be considered as a curative option,in particular considering the excellent long-term results recently published by the Oslo group(4).

Optimization of the future remnant liver:review of the current strategies in Europe

Liver resection still represent the treatment of choice for liver malignancies,but in some cases inadequate future remnant liver(FRL)can lead to post hepatectomy liver failure(PHLF)that still represents the most common cause of death after hepatectomy.Several strategies in recent era have been developed in order to generate a compensatory hypertrophy of the FRL,reducing the risk of post hepatectomy liver failure.Portal vein embolization,portal vein ligation,and ALLPS are the most popular techniques historically adopted up to now.The liver venous deprivation and the radio-embolization are the most recent promising techniques.Despite even more precise tools to calculate the relationship among volume and function,such as scintigraphy with^(99m)Tc-mebrofenin(HBS),no consensus is still available to define which of the above mentioned augmentation strategy is more adequate in terms of kind of surgery,complexity of the pathology and quality of liver parenchyma.The aim of this article is to analyse these different strategies to achieve sufficient FRL.

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)?

Background:Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)is not always reliable with currently available scores,particularly in patients with primary liver tumor.This study aims to(I)to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and(II)to create a score predicting 90-day mortality preoperatively.Methods:Thirteen high-volume centers participated in this retrospective multicentric study.A risk analysis based on patient characteristics,underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment(CAPRA)score.A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index(CCI),the age-adjusted CCI(aCCI),the ALPPS risk score before Stage 1(ALPPS-RS1)and Stage 2(ALPPS-RS2).The model was internally validated applying bootstrapping.Results:A total of 451 patients were included.Mortality was 14.4%.The CAPRA score is calculated based on the following formula:(0.1×age)−(2×BSA)+1(in the presence of primary liver tumor)+1(in the presence of severe cardiovascular disease)+2(in the presence of moderate or severe diabetes)+2(in the presence of renal disease)+2(if classic ALPPS is planned).The predictive ability was 0.837 for the CAPRA score,0.443 for CCI,0.519 for aCCI,0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2.After 1,000 cycles of bootstrapping the C statistic was 0.793.The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70.Conclusions:Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure.By assessing the patient’s preoperative condition in relation to ALPPS,the CAPRA score has a very good ability to predict postoperative mortality.

Optimizing future remnant Iiver prior to major hepatectomies:increasing volume while decreasing morbidity and mortality

Post hepatectomy liver failure(PHLF)remains the most dreaded complication in major hepatectomies.Adequate future remnant liver(FRL)plays a pivotal role in prevention of PHLF.Pre-operative portal vein embolization(PVE)has become standard of care for increasing the FRL in preparation for major hepatectomies.Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)has also been used,though has demonstrated a substantial risk of morbidity and mortality.However,there are many situations in which PVE achieves an inadequate extent of hypertrophy,potential increasing the risk of PHLF.Panaro and colleagues explore their data with a prospective review of preoperative PVE versus liver venous deprivation(LVD)regarding intra and post-operative complications,as well as,histologic findings(1).This study adds to a growing body of literature assessing the benefit of LVD over PVE and ALPPS both,in regards to increased rate of hypertrophy,improvement in FRL,in the face of similar morbidity/mortality rates compared to PVE.

Liver transplantation for irresectable colorectal liver metastases:still a contraindication?

Liver transplantation(LT)for irresectable colorectal cancer liver metastases(i-CRLM)has been considered up to now an absolute contraindication due to unfavorable outcomes,scarcity of grafts and ethical considerations.Recently,promising results of the Norwegian SECA trial raise the question of the utility of LT for i-CRLM with a 5-year survival rate of 60%(1).However,some concerns should be considered as to oncological selection criteria(when to perform the transplantation?)and the source of liver grafts:deceased donor at cost of recipient listed for standard indication or living donor in a population with a higher risk of recurrence.