Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) in Chronic hepatitis-Related Hepatocellular Carcinoma (HCC)

Abstract

Background: ALPPS has been introduced as a novel approach to induce liver hypertrophy in patients with insufficient future liver remnant (FLR) contemplating for major hepatectomy in colorectal liver metastasis. Our aim was to evaluate the suitability and outcome of ALPPS for hepatitis-related HCC when compared with portal vein embolization (PVE). Methods: Patients with Child A cirrhosis and FLR <35% of estimated total liver volume (ESLV) were selected for ALPPS. Insitu split was performed by anterior approach in stage I. Portal haemodynamics were studied intraoperatively. No bag nor drain was placed in stage I. Postoperative outcomes were compared with PVE matched for age, liver function and tumor characteristics. Results: From October 2013 to May 2016, 29 patients with a median age of 60 (hepatitis B, n = 28; hepatitis C, n = 1) underwent ALPPS. The tumor size was 8.6 cm (1.3–17.0 cm). Preoperative FLR was 313.0 ml and the median FLR/ESLV was 26.1% with an ICG value at 15 minutes of 11.3%. Portal flow to FLR increased from 200.0 ml/min to 542.5 ml/min after portal vein ligation, and subsequently to 737.5 ml/min after in-situ split. As a result, FLR volume increased by 50.7% after 6 days with an FLR of 498.3 ml and FLR/ESLV of 38.5%. All patients proceeded to stage II operations (right trisectionectomy, n = 4; extended right hepatectomy, n = 10, right hepatectomy n = 15) without inter-stage complications. ALPPS induced greater FLR hypertrophy than PVE (daily FLR gain: 7.0% vs. 0.8%, p < 0.001) without increased morbidity (10.3% vs. 32.1%) and mortality (6.9% vs. 7.1%, p = 1.000). The 1-year tumor recurrence rate for ALPPS and PVE were similar (TNM I/II: 0% vs. 20.5%; TNM III: 53.8% vs. 52.2%, respectively). Conclusion: ALPPS induced FLR hypertrophy in chronic liver disease by substantial flow augmentation with similar oncological outcome as PVE. The entire course of treatment could be completed in a timely manner within one hospitalization.