- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02184182
Laparoscopic Microwave Ablation and Portal Vein Ligation for Staged Hepatectomy (LAPS) (LAPS)
Liver Resection After Portal Vein Ligation / Embolization and Transection Plane Devascularization With Radio Frequency / Microwave: Pilot Study on Primary and Secondary Liver Tumors
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.
Study Overview
Status
Conditions
Intervention / Treatment
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
Study Type
Enrollment (Anticipated)
Phase
- Phase 2
Contacts and Locations
Study Contact
- Name: Umberto Cillo, MD, PhD
- Phone Number: +390498211846
- Email: cillo@unipd.it
Study Contact Backup
- Name: Enrico Gringeri, MD, PHD
- Phone Number: +390498211846
- Email: enrico.gringeri@unipd.it
Study Locations
-
-
-
Padova, Italy, 35100
- Recruiting
- Chirurgia Epatobiliare e Trapianto Epatico - Azienda Ospedaliera di Padova
-
Contact:
- Umberto Cillo
- Phone Number: +390498211846
- Email: cillo@unipd.it
-
Contact:
- Enrico Gringeri
- Phone Number: +390498211846
- Email: enrico.gringeri@unipd.it
-
Principal Investigator:
- Umberto Cillo
-
Sub-Investigator:
- Enrico Gringeri
-
Sub-Investigator:
- Domenico Bassi
-
Sub-Investigator:
- Riccardo Boetto
-
Sub-Investigator:
- Francesco Enrico D'Amico
-
Sub-Investigator:
- Marina Polacco
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
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
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: N/A
- Interventional Model: Single Group Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: VLS ablation/portal ligation/hepatectomy
Step1:
Step 2: only if FRL/body weight > 0.5 - laparoscopic/laparotomic right trisectionectomy |
Step1:
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
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Percentage of R0 resections
Time Frame: 30days after Step2
|
Percentage of operations in which a complete oncological radicality (R0) is achived
|
30days after Step2
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Perioperative mortality (3 months)
Time Frame: 3 moths
|
Percentage of perioperative mortality (3 months)
|
3 moths
|
Perioperative complication (Clavien Classification)
Time Frame: 1 month
|
Percentage of perioperative complication described using Clavien Dindo Classification
|
1 month
|
Time to progression
Time Frame: 12 months
|
12 months
|
|
Overall survival
Time Frame: 12 and 24 months
|
Overall survival at 12 and 24 months after surgery
|
12 and 24 months
|
disease free survival
Time Frame: 12 months
|
12 months
|
|
hepatic diesease free survival
Time Frame: 12 months
|
12 months
|
Collaborators and Investigators
Sponsor
Investigators
- Study Chair: Umberto Cillo, MD PhD, Azienda Ospedaliera di Padova
Publications and helpful links
General Publications
- Jaeck D, Oussoultzoglou E, Rosso E, Greget M, Weber JC, Bachellier P. A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases. Ann Surg. 2004 Dec;240(6):1037-49; discussion 1049-51. doi: 10.1097/01.sla.0000145965.86383.89.
- Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, Fichtner-Feigl S, Lorf T, Goralcyk A, Horbelt R, Kroemer A, Loss M, Rummele P, Scherer MN, Padberg W, Konigsrainer A, Lang H, Obed A, Schlitt HJ. 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. Ann Surg. 2012 Mar;255(3):405-14. doi: 10.1097/SLA.0b013e31824856f5.
- Lang H, Sotiropoulos GC, Brokalaki EI, Radtke A, Frilling A, Molmenti EP, Malago M, Broelsch CE. Left hepatic trisectionectomy for hepatobiliary malignancies. J Am Coll Surg. 2006 Sep;203(3):311-21. doi: 10.1016/j.jamcollsurg.2006.05.290. Epub 2006 Jul 13.
- Farges O, Belghiti J, Kianmanesh R, Regimbeau JM, Santoro R, Vilgrain V, Denys A, Sauvanet A. Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg. 2003 Feb;237(2):208-17. doi: 10.1097/01.SLA.0000048447.16651.7B.
- Tartter PI. The association of perioperative blood transfusion with colorectal cancer recurrence. Ann Surg. 1992 Dec;216(6):633-8. doi: 10.1097/00000658-199212000-00004.
- Donati M, Stavrou GA, Oldhafer KJ. Current position of ALPPS in the surgical landscape of CRLM treatment proposals. World J Gastroenterol. 2013 Oct 21;19(39):6548-54. doi: 10.3748/wjg.v19.i39.6548.
- 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.
- 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.
- 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.
- 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.
Study record dates
Study Major Dates
Study Start
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 2934P
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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