After viewing the video published in your magazine, “Laparoscopic hybrid mini-ALPPS using transmesenteric intraoperative portal embolization for locally advanced intrahepatic cholangiocarcinoma”, we would like to share some of our thoughts.
First of all, we would like to congratulate the authors for satisfactorily performing such a demanding surgery, thanks to which the patient is disease-free 18 months later. Intrahepatic cholangiocarcinoma is an aggressive tumor, and the mainstay of its treatment is surgical resection with free margins. In the case of large tumors, resection may be influenced by the future liver remnant.1,2 Among the alternatives to overcome this difficulty is ALPPS surgery, which allows for rapid hypertrophy with a two-stage surgery.3–5 Although it has been related to high morbidity and mortality, careful patient selection and the appearance of variants like the mini-ALPPS have managed to improve postoperative results.6 However, given the case presented by the authors, we believe that other alternatives could be considered.
On the one hand, hepatic venous deprivation is a technique that adds embolization of the right and middle suprahepatic veins to classic portal embolization. Among its advantages over standard portal embolization is that it achieves a greater future liver remnant in less time, with similar safety.7 Therefore, it is especially indicated in tumors that affect the right liver and segment IV. Although this hypertrophy requires more time than the ALPPS intervention, it allows for tumor resection in a single intervention. Furthermore, it does not involve ligation of the inferior mesenteric vein, which is performed in the video presented.
Another alternative to consider is surgery after radioembolization.8 With this technique, it is possible to perform local treatment of the tumor by depositing radioactive microspheres in the tributary arteries of the tumor and, in addition, achieve contralateral hypertrophy by injecting part of the radiation into a lobar artery.9–11 Although achieving hypertrophy requires more time, it has the advantage of offering treatment of the tumor from the start, which may even involve a reduction in its size that facilitates future surgery. Furthermore, this circumstance enables us to select patients with stable disease over time before surgery, which can improve oncological results by reducing recurrence rates.
The treatment of this type of tumors is challenging for the surgeon. Adequate planning is necessary to achieve resection with free margins, while guaranteeing a sufficient liver remnant. In this context, we believe that double deprivation and radioembolization may be alternatives that facilitate subsequent surgery.
Conflict of interestsThe authors of this article have no conflicts of interests to declare related to the development and final results of this paper.
FundingThis research paper has received no specific funding from public, commercial or non-profit entities.
