La contribución del lóbulo hepático deportalizado a la regeneración hepática en la técnica ALPPS-torniquete

Abstract

Objective: In September 2011, at the Virgen de la Arrixaca Clinic University Hospital, the first modification of the ALPPS technique was performed with the intention of reducing the aggressiveness of this first intervention of ALPPS, this technique was called Tourniquet ALPPS or T-ALPPS. The main objective of the present thesis is to analyze the factors that influence liver regeneration that occurs in the remaining liver volume and in the deportalized lobe after the T-ALPPS technique in human livers. Methods: 25 patients undergoing T-ALPPS technique were selected between January 2013 and July 2018. During the first procedure, a right portal ligation associated with tourniquet placement in two different positions is performed first: 1. For a right hepatectomy in the second time, after removal of the left lobe lesions, the tourniquet is placed at Cantlie's line by hanging maneuver. A groove is made at this level and the right extraglissonian tourniquet is passed to avoid occlusion of the right hepatic artery. 2. In case of performing a right trisectionectomy during T-ALPPS second stage, the tourniquet is placed in the umbilical fissure between the middle and left suprahepatic vein, passing through Rex's recess and passing the tourniquet extraglissonian left, knotting the tourniquet in the umbilical fissure. Three biopsies were taken in each lobe during the T-ALPPS technique. These biopsies were analyzed by quantitative analysis using reverse transcriptase polymerase chain reaction. Subsequently, a comparative study of the biopsies from the first time (2A-ST1) and the second time (1A-ST2) was carried out, with respect to the basal biopsies taken at the beginning of the first time (1A-ST1). Results: Out of the total of 25 patients in our series, 18 were male (72%) with an age of 62 years. The most frequent indication was colorectal cancer metastases (88%). The main finding is centered in the deportalized lobe, since during the first surgical time there is an increase of HGF in this lobe at 60 minutes after performing the technique, compared to baseline biopsy levels. This increase was maintained in the biopsies taken during the second intervention, with an increase of some proinflammatory factors and hypoxia only. However, this increase in HGF did not translate into an increase in the Ki-67 proliferative index in LHD. Another important finding occurs in the VHR, where an early increase in HGF was also detected (p=0.002), from 60 minutes after the technique, related to an elevation of proinflammatory factors, hypoxia and factors that regulate the cell cycle, without an increase in apoptotic factors. In contrast to the deportalized lobe, in the remaining hepatic volume, after 10 days the HGF value returns to normal values, so it seems that the phenomenon of liver regeneration has ended in the second intervention. Conclusions: The deportalized lobe maintains part of the overall liver function of the individual, acting as an "auxiliary" liver and producing HGF that could act as a regenerative stimulus on the future liver remnant through the systemic circulation.