Laparoscopic Microwave Ablation and Portal Vein Ligation for Staged Hepatectomy (LAPS)

NCT ID: NCT02184182

Last Updated: 2014-07-09

Basic Information

• Recruitment Status: UNKNOWN
• Clinical Phase: PHASE2
• Total Enrollment: 10 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2014-06-30
• Study Completion Date: 2017-06-30

Brief Summary

One of the limiting factors in the execution of a liver resection, in particular an extended liver resection, it's represented by the future remnant liver (FRL) after hepatic surgery. In cases of normal organ function an FRL of 25% is considered sufficient. In case of impaired hepatic function or a history of chemotherapy, it is considered safe if at least of 40%.

Many strategies have been developed and proposed to increase the resectability in patients undergoing major liver resections.

One of these is a new two-stage technique proposed recently by a group of German surgeons. This approach consists in the ligation of the right portal vein associated with resection of the liver along the falciform ligament (step 1). Step 2, after a period of 9 days (median - 5-25 days), after a volumetric CT to ensure an adeguate hypertrophy of the left lateral lobe due to the combination of right portal occlusion and segment 4 devascularization, the patient undergo a right trisectionectomy. The hypertrophy of the left lateral lobe is shown to be of 74%, higher than any other techniques of ligation or portal embolizatiol proposed in the literature.

On the basis of the clinical experiences reported the investigators designed a new protocol of two-stage hepatic resection for the treatment of primary or secondary tumors of the right lobe. Step1: laparoscopic radio frequency / microwave ablation of the future transection plane between segment 4 and left lateral lobe and surgical ligation or embolization of the right portal vein. The ablation has the purpose to devascularize the segment 4 and has the same significance of the resection of the liver along the falciform ligament described by the Regensburg group.

Step2: After a period of time of 9 ± 2 days, following a volumetric CT showing an adequate liver volume gain (ratio FRL / patient body weight> 0.5), the patient undergo the second-stage surgery: laparoscopic/ laparotomic right trisectionectomy.

Detailed Description

In patients with primary or metastatic liver tumors, the only potentially curative therapeutic option is represented by hepatic resection. Nowdays extended resections can be performed with acceptable morbidity and mortality. There is no unanimous definition on the criteria of resectability and the ability to perform a more or less extensive liver resection is deferred to the expertise of the center and the surgical team. The investigators will consider a tumor resectable if the surgical procedure does not damage vital structures, the normal function of the organ is preserved and and the tumor is completely removed (R0 resection). One of the limiting factors in the execution of a liver resection, in particular if it is extended, it's represented by the future remnant liver (FRL) after hepatic resection. In cases of normal organ function an FRL of 25% is considered sufficient. In case of impaired hepatic function or a history of chemotherapy, it is considered safe if at least of 40%.

Many methods have been developed and proposed to increase the resectability in patients undergoing major liver resections. In case of bilobar tumor, a two-step approach (two-stage hepatectomy)have been proposed. This procedure implies that one of the two lobes is initially freed of disease by tumor resection or ablation. After achieving an adequate compensatory hypertrophy of the lobe freed by the tumor (usually 4-6 weeks),a contralateral liver resection can be done to treat the remnant tumor.

To increase the FRL another approach is to occlude the portal branches towards one of liver lobes. This can be done with a surgical ligation (laparotomy or laparoscopy) or radiologically, using portal embolization. The technique allows to increase from 10% to 46% of the FRL with the possibility of obtaining a resection R-0 in 70-100% of cases. It is unclear whether there is any difference between the methods of portal occlusion (ligation vs embolization). To further increase hypertrophy after portal occlusion in liver tumors occupying the right liver, some researchers proposed to embolize the portal branches of segment 4th together with the right portal vein.

The group of Regensburg has introduced a new technique in two stages for tumors of the right lobe, which combines the methods mentioned above. This two-stage approach consists in the ligation of the right portal vein associated with resection of the liver along the falciform ligament (step 1). Step 2, after a period of 9 days (median - 5-25 days), after a volumetric CT to ensure an adeguate hypertrophy of the left lateral lobe, the patient undergo a right trisectionectomy. The hypertrophy of the left lateral lobe is shown to be of 74%, higher than any other techniques of ligation or portal embolizatiol proposed in the literature.

The rationale of this technique is the complete portal devascularization of the right lobe plus segment 4 that produce a greater stimulus to hypertrophy of the left lateral segments. This occurs in less time than other methods above described and allows to reduce the timeframe between the two steps and minimizes the risk of interprocedural progression of the underlying disease (incidence of drop outs in the two-stage hepatectomy of 20% for progression disease).

The morbidity of this two-stage approach was 44% (complications of Clavien grade III and IV) that mimics the data reported in the literature for extended hepatic resections (20-50%). The 12%mortality rate was similar to one described by Lang et al for left trisegmentectomies.

On the basis of the clinical experiences reported the investigators designed a new protocol of two-stage hepatic resection for the treatment of primary or secondary tumors of the right lobe. Step1: laparoscopic radio frequency / microwave ablation of the future transection plane between segment 4 and left lateral lobe and surgical ligation or embolization of the right portal vein. The ablation has the purpose to devascularize the segment 4 and has the same significance of the resection of the liver along the falciform ligament described by the Regensburg group.

Step2: After a period of time of 9 ± 2 days, following a volumetric CT showing an adequate liver volume gain (ratio FRL / patient body weight> 0.5), the patient undergo the second-stage surgery: laparoscopic/ laparotomic right trisectionectomy

Conditions

Liver Tumors

Study Design

• Allocation Method: NA
• Intervention Model: SINGLE_GROUP
• Primary Study Purpose: TREATMENT
• Blinding Strategy: NONE

Study Groups

VLS ablation/portal ligation/hepatectomy

Step1:

• exploratory laparoscopy to exclude extrahepatic disease
• right portal vein ligation if surgically feasible
• RF/MW ablation on the future line of transection (of segment 4 close to left lateral lobe)
• radiological portal embolization within 48h form the laparoscopic procedure if the right portal vein ligation is not feasible CT volumetric scan to evaluate the left lateral lobe hypertrophy after 9±2 from Step 1

Step 2: only if FRL/body weight > 0.5

• laparoscopic/laparotomic right trisectionectomy

Group Type: EXPERIMENTAL

VLS ablation/portal ligation/hepatectomy

Intervention Type: PROCEDURE

Step1:

• exploratory laparoscopy to exclude extrahepatic disease
• right portal vein ligation if surgically feasible
• RF/MW ablation on the future line of transection (of segment 4 close to left lateral lobe)
• radiological portal embolization within 48h form the laparoscopic procedure if the right portal vein ligation is not feasible

CT volumetric scan to evaluate the left lateral lobe hypertrophy after 9±2 from Step 1

Step 2: only if FRL/body weight > 0.5

• laparoscopic/laparotomic right trisectionectomy

Interventions

VLS ablation/portal ligation/hepatectomy

Step1:

• exploratory laparoscopy to exclude extrahepatic disease
• right portal vein ligation if surgically feasible
• RF/MW ablation on the future line of transection (of segment 4 close to left lateral lobe)
• radiological portal embolization within 48h form the laparoscopic procedure if the right portal vein ligation is not feasible

CT volumetric scan to evaluate the left lateral lobe hypertrophy after 9±2 from Step 1

Step 2: only if FRL/body weight > 0.5

• laparoscopic/laparotomic right trisectionectomy

Intervention Type: PROCEDURE

Other Intervention Names

VLS Ablation & Portal Vein Ligation for Staged Hepatectomy

Eligibility Criteria

Inclusion Criteria

• Patients aged between 18 and 70 years (M and F)
• Liver tumors that interests the right hepatic lobe (segments 4,5,6,7,8) with possible involvement of the caudate lobe (segment 1) or bilobar disease with less than 3 lesions in the left lateral lobe without vascular involvement and amenable to surgically resectable or ablation in the Step1.
• Absence of extrahepatic disease
• Normal hepatic function (total bilirubin <3 mg / dL)
• Performance status: ECOG 0
• In case of liver cirrhosis MELD score <9
• Patients without prior chemotherapy or with previous chemotherapy but with response disease
• Patients who give their consent to the intervention

Exclusion Criteria

• CT Evidence of involvement of the major vessels in the future remnant liver
• Presence of more than 3 nodules in the left lateral lobe
• Presence of extrahepatic disease
• Severe hepatic impairment
• Age> 70 years
• Previous liver surgery (prior liver resections)
• Patient receiving chemotherapy with documented disease progression

• Minimum Eligible Age: 18 Years
• Maximum Eligible Age: 70 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Azienda Ospedaliera di Padova

OTHER

Sponsor Role: lead

Responsible Party

Prof. Umberto Cillo

full professor of general surgery, MD, PhD

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Umberto Cillo, MD PhD

Role: STUDY_CHAIR

Azienda Ospedaliera di Padova

Locations

Chirurgia Epatobiliare e Trapianto Epatico - Azienda Ospedaliera di Padova

Padua, Padova, Italy

Site Status: RECRUITING

Countries

Italy

Central Contacts

Umberto Cillo, MD, PhD

Role: CONTACT

cillo@unipd.it

+390498211846

Enrico Gringeri, MD, PHD

Role: CONTACT

enrico.gringeri@unipd.it

+390498211846

Facility Contacts

Umberto Cillo

Role: primary

cillo@unipd.it

+390498211846

Enrico Gringeri

Role: backup

enrico.gringeri@unipd.it

+390498211846

References

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Reference Type: BACKGROUND

PMID: 22330038 (View on PubMed)

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Reference Type: BACKGROUND

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Reference Type: BACKGROUND

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Reference Type: BACKGROUND

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Reference Type: BACKGROUND

PMID: 24151380 (View on PubMed)

Lang H, Sotiropoulos GC, Fruhauf NR, Domland M, Paul A, Kind EM, Malago M, Broelsch CE. Extended hepatectomy for intrahepatic cholangiocellular carcinoma (ICC): when is it worthwhile? Single center experience with 27 resections in 50 patients over a 5-year period. Ann Surg. 2005 Jan;241(1):134-43. doi: 10.1097/01.sla.0000149426.08580.a1.

Reference Type: BACKGROUND

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Are C, Iacovitti S, Prete F, Crafa FM. Feasibility of laparoscopic portal vein ligation prior to major hepatectomy. HPB (Oxford). 2008;10(4):229-33. doi: 10.1080/13651820802175261.

Reference Type: BACKGROUND

PMID: 18806869 (View on PubMed)

de Santibanes E, Alvarez FA, Ardiles V. How to avoid postoperative liver failure: a novel method. World J Surg. 2012 Jan;36(1):125-8. doi: 10.1007/s00268-011-1331-0.

Reference Type: BACKGROUND

PMID: 22045448 (View on PubMed)

van Lienden KP, Hoekstra LT, Bennink RJ, van Gulik TM. Intrahepatic left to right portoportal venous collateral vascular formation in patients undergoing right portal vein ligation. Cardiovasc Intervent Radiol. 2013 Dec;36(6):1572-1579. doi: 10.1007/s00270-013-0591-5. Epub 2013 Mar 13.

Reference Type: BACKGROUND

PMID: 23483283 (View on PubMed)

Related Links

http://www.fegatochirurgia.com

Online resource of Chirurgia Epatobiliare e Trapianto Epatico, Università degli Studi di Padova

Other Identifiers

2934P

Identifier Type: -

Identifier Source: org_study_id