The ALPPS procedure for hepatocellular carcinoma
Introduction
The main limiting factor of hepatic resection for hepatocellular carcinoma (HCC) associated with liver cirrhosis is the amount of the future liver remnant (FLR). In order to maintain sufficient liver function and avoid small for size syndrome or death due to liver failure, it is highly recommended in cases of underlying liver disease the FLR should be 40% of the total liver volume (TLV).1, 2 One method developed to increase resectability and reduce the incidence of postoperative complications is the occlusion of the right or left portal vein (PV) by preoperative portal vein embolisation (PVE) in the tumour-bearing liver as an efficient method of increasing the FLR volume.1, 2, 3 PVE has been largely adopted and has been shown to induce a hypertrophy rate of 35–69% in 45 days.4, 5 However this strategy cannot always be applied or be successful for the following reasons: (1) the PV is occluded by the tumour, (2) aggressive tumour with early progression of malignant disease, and (3) inadequate FLR.
During the last few months there has been considerable debate about the Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure to induce a rapid hypertrophy of the FLR in patients with non-resectable liver tumours. This novel concept of a two-stage hepatectomy seems to overcome the above mentioned drawbacks of conventional PVE.6, 7 However early experience with ALLPS has been reported in patients with liver tumours mainly non-cirrhotic livers while its application for HCC in cirrhotic livers has been very limited.6, 7, 8
We have applied this new strategy in three cases of HCC in a cirrhotic liver. This paper comprises a presentation of the technical problems encountered and the results following application of the procedure.
Section snippets
Eligibility criteria
The ALPPS procedure was applied to three patients with HCC in a cirrhotic liver. All cases were discussed by a multidisciplinary panel of hepatologists, liver surgeons, interventional radiologists and anaesthetists. Patients were considered eligible for surgical resection if they had a preserved liver function (serum bilirubin level <1.5 mg/dl, INR<1.3, and no signs of liver decompensation), oesophageal varices <grade 1, platelets count >80 × 10/L and absence of ascites. Child-Pugh, Model for
Results
Between September 2012 and May 2013, three patients underwent ALPSS procedure in our division of general surgery and liver transplantation. Indication for ALLPS in cirrhosis was HCC in all cases. Patient characteristics and pre-operative liver function are reported in Table 1. One patient had a previous left colectomy (four months earlier) for a sigmoid cancer (pT3 N2 G3) performed in another local hospital.
Two patients had macro-vascular invasion: (1) right branch of PV, (2) middle hepatic
Discussion
A well known strategy, when performing a major liver resection (≥3 segments) on a diseased liver in order to decrease the mortality/morbidity of procedure, is to induce hypertrophy of the tumour-free lobe by occlusion of the right portal vein. This can be achieved by radiological PVE or surgical PVL in open or laparoscopic fashion. Four–six weeks later, surgery can be safely performed with tumour removal after hypertrophy of FLR (1–5).
However this strategy has some limitations: 1) it cannot be
Conclusions
In conclusion, the ALPPS procedure seems to be feasible even in the context of a cirrhotic liver which shows the capacity to reach a sufficient FLR within a shorter interval of time.
Conflict of interest
All authors do not have conflict of interest.
Acknowledgement
-This paper has not been funded.
References (32)
- et al.
Present status and future perspectives of preoperative portal vein embolization
Am J Surg
(2009) - et al.
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): TIPS and Tricks
J Gastrointest Surg
(2013) - et al.
Using ALPPS to induce rapid liver hypertrophy in a patient with hepatic fibrosis and portal vein thrombosis
J Gastrointest Surg
(2013) - et al.
Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS)
Surgery
(2011) - et al.
ALPPS in right trisectionectomy: a safe procedure to avoid postoperative liver failure?
J Gastrointest Surg
(2013) - et al.
Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion – an extension of the ALPPS approach
Eur J Surg Oncol
(2013) - et al.
EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma
J Hepatol
(2012) - et al.
Improved long-term survival after major resection for hepatocellular carcinoma: a multicenter analysis based on a new definition of major hepatectomy
J Gastrointest Surg
(2013) - et al.
Preoperative portal vein embolization for extended hepatectomy
Ann Surg
(2003) - et al.
Portal vein embolization before right hepatectomy
Ann Surg
(2003)
Preoperative portal vein embolizaion for major liver resection: a meta-analysis
Ann Surg
Impact of portal vein embolization on long-term survival of patients with primarily unresectable colorectal liver metastases
Br J Surg
Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling two-staged extended right hepatic resection in small for size settings
Ann Surg
Portal vein embolization before liver resection: a systematic review
Cardiovasc Intervent Radiol
The Brisbane 2000 terminology of hepatic anatomy and resections
HPB
Le Foie études anatomiques et chirurgicales
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