Percutaneous Microwave Ablation Liver Partition and Portal Vein Embolization for Rapid Liver Regeneration: A Minimally Invasive First Step of ALPPS for Hepatocellular Carcinoma. Ann Surg. 2016;264:e1-e2. [PMID: 26967629 PMCID: PMC4902319 DOI: 10.1097/sla.0000000000001707]

Comparison of clinical efficacy between LAPS and ALPPS in the treatment of hepatitis B virus-related hepatocellular carcinoma

Background

Insufficient post-operative future liver remnant (FLR) limits the feasibility of hepatectomy for patients. Staged hepatectomy is an effective surgical approach that can improve the resection rate of hepatocellular carcinoma (HCC). This study aimed to compare the safety and efficacy of laparoscopic microwave ablation and portal vein ligation for staged hepatectomy (LAPS) and classical associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in the treatment of hepatitis B virus (HBV)-related HCC.

Methods

Clinical data of patients with HBV-related HCC who underwent LAPS or ALPPS in our institute between January 2017 and May 2022 were retrospectively analysed.

Results

A total of 18 patients with HBV-related HCC were retrospectively analysed and divided into the LAPS group (n = 9) and ALPPS group (n = 9). Eight patients in the LAPS group and eight patients in the ALPPS group proceeded to a similar resection rate (88.9% vs 88.9%, P = 1.000). The patients undergoing LAPS had a lower total comprehensive complication index than those undergoing ALPPS but there was not a significant different between the two groups (8.66 vs 35.87, P = 0.054). The hypertrophy rate of FLR induced by ALPPS tended to be more rapid than that induced by LAPS (24.29 vs 13.17 mL/d, P = 0.095). The 2-year recurrence-free survival (RFS) was 0% for ALPPS and 35.7% for LAPS (P = 0.009), whereas the 2-year overall survival for ALPPS and LAPS was 33.3% and 100.0% (P = 0.052), respectively.

Conclusions

LAPS tended to induce lower morbidity and FLR hypertrophy more slowly than ALPPS, with a comparable resection rate and better long-term RFS in HBV-related HCC patients.

Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)

Background

Primary liver cancer, of which around 75-85% is hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

Summary

Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China in June 2017, which were updated by the National Health Commission in December 2019, additional high-quality evidence has emerged from researchers worldwide regarding the diagnosis, staging, and treatment of liver cancer, that requires the guidelines to be updated again. The new edition (2022 Edition) was written by more than 100 experts in the field of liver cancer in China, which not only reflects the real-world situation in China but also may reshape the nationwide diagnosis and treatment of liver cancer.

Key Messages

The new guideline aims to encourage the implementation of evidence-based practice and improve the national average 5-year survival rate for patients with liver cancer, as proposed in the "Health China 2030 Blueprint."

The Effect of Microwave and Radiofrequency Ablation (MWA/RFA) on Liver Volume in Patients with Primary and Secondary Liver Tumours: A Retrospective Analysis

PURPOSE

It is known that thermal liver ablation can induce liver hypertrophy. However, exact impact in liver volume remains unclear. The aim of this study is to assess the influence of radiofrequency or microwave ablation (RFA/MWA) on liver volume in patients with primary and secondary liver lesions. Findings can be relevant in assessing the potential extra benefit of thermal liver ablation in preoperatively performed liver hypertrophy inducing procedures, such as portal vein embolization (PVE).

METHODS

Between January 2014-May 2022, 69 invasive treatment naïve patients with primary (n = 43) or secondary/metastatic (n = 26) liver lesions (in all segments, except in segments II/III) treated percutaneously by RFA/MWA were included. Total liver volume (TLV), segment II + III volume (serving as "distant liver volume"), ablation zone volume and absolute liver volume (ALV, calculated by subtracting the ablation zone volume from the TLV) were the study outcomes.

RESULTS

ALV in patients with secondary liver lesions increased to a median percentage of 106.87% (IQR = 99.66-113.03%, p = 0.016), volume of segments II/III increased to a median percentage of 105.81% (IQR = 100.06-115.65%, p = 0.003). ALV and segments II/III in patients with primary liver tumours remained stable, with a median percentage of 98.72% (IQR = 92.99-108.35%, p = 0.856) and 100.43% (IQR = 92.85-109.41%, p = 0.699), respectively.

CONCLUSION

In patients with secondary liver tumours, ALV and segments II/III increased after MWA/RFA by an average of approximately 6%, while ALV in patients with primary liver lesions remained unchanged. Besides the curative intent, these findings indicate the potential added benefit of thermal liver ablation on FLR hypertrophy inducing procedures in patients with secondary liver lesions.

LEVEL OF EVIDENCE

Level 3, non-controlled retrospective cohort study.

Application of systemic treatment in conversion therapy options for liver cancer

Radical hepatectomy is the main treatment method to improve the prognosis of patients with intermediate and early-stage liver cancer. Most liver cancer patients in China are in the advanced stage at the initial diagnosis, losing the opportunity for surgical treatment. Therefore, it is essential to down-stage unresectable liver cancer to resectable liver cancer clinically, which is an important way to improve patients’ survival and a hotspot of current clinical research. In recent years, with the increase in effective treatment methods for liver cancer, the resection rate of conversion surgery for unresectable advanced liver cancer has been significantly improved, and a growing number of patients benefit from conversion therapy. This article mainly reviews the connotation of conversion therapy for liver cancer, the patient selection, the selection of conversion strategy, the timing of sequential operations, the scheme and safety, etc.

Sequential Portal Vein Embolization and Percutaneous Radiofrequency Ablation for Future Liver Remnant Growth: A Minimally Invasive Alternative to ALPPS Stage-1 in Treatment of Hepatocellular Carcinoma

Background: To evaluate the feasibility and efficacy of sequential portal vein embolization (PVE) and radiofrequency ablation (RFA) (PVE+RFA) as a minimally invasive variant for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) stage-1 in treatment of cirrhosis-related hepatocellular carcinoma (HCC).

Methods: For HCC patients with insufficient FLR, right-sided PVE was first performed, followed by percutaneous RFA to the tumor as a means to trigger FLR growth. When the FLR reached a safe level (at least 40%) and the blood biochemistry tests were in good condition, the hepatectomy was performed. FLR dynamic changes and serum biochemical tests were evaluated. Postoperative complications, mortality, intraoperative data and long-term oncological outcome were also recorded.

Results: Seven patients underwent PVE+RFA for FLR growth between March 2016 and December 2019. The median baseline of FLR was 353 ml (28%), which increased to 539 (44%) ml after 8 (7–18) days of this strategy (p < 0.05). The increase of FLR ranged from 40% to 140% (median 47%). Five patients completed hepatectomy. The median interval between PVE+RFA and hepatectomy was 19 (15–27) days. No major morbidity ≥ III of Clavien-Dindo classification or in-hospital mortality occurred. One patient who did not proceed to surgery died within 90 days after discharge. After a median follow-up of 18 (range 3–50) months, five patients were alive.

Conclusion: Sequential PVE+RFA is a feasible and effective strategy for FLR growth prior to extended hepatectomy and may provide a minimally invasive alternative for ALPPS stage-1 for treatment of patients with cirrhosis-related HCC.

Conversion therapy for primary liver cancer: Indications and selective strategies

Primary liver cancer has an insidious onset and no specific symptoms at early stage. Most patients are in the middle or advanced stage when diagnosed, and only 20%-40% of patients meet the criteria for radical resection. At present, surgical resection is still the main radical treatment for primary liver cancer, but factors such as liver function decompensation, too large tumor volume, too small future liver remnant, intrahepatic multiple metastasis, tumor thrombus invading the large vessels or bile duct, and distant metastasis limit the application of surgical resection or liver transplantation. In recent years, with the advances of basic research of primary liver cancer, the development of surgical techniques and equipment, as well as the development of new molecular targeted drugs and immunotherapy drugs, a part of unresectable patients with primary liver cancer can receive conversion therapy to improve liver function, minimize tumor volume, minimize or inactivate tumor thrombus, and increase the residual liver volume. Following conversion therapy, patients with primary liver cancer can undergo surgical resection or liver transplantation, which greatly improve the therapeutic efficacy and patient survival.

Guidelines for the Diagnosis and Treatment of Hepatocellular Carcinoma (2019 Edition)

BACKGROUND

Primary liver cancer, around 90% are hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

SUMMARY

Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer (2017 Edition) in 2018, additional high-quality evidence has emerged with relevance to the diagnosis, staging, and treatment of liver cancer in and outside China that requires the guidelines to be updated. The new edition (2019 Edition) was written by more than 70 experts in the field of liver cancer in China. They reflect the real-world situation in China regarding diagnosing and treating liver cancer in recent years.

KEY MESSAGES

Most importantly, the new guidelines were endorsed and promulgated by the Bureau of Medical Administration of the National Health Commission of the People's Republic of China in December 2019.

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Unresectable Hepatitis B Virus-related Hepatocellular Carcinoma: A Single Center Study of 45 Patients

OBJECTIVE

The aim of the study is to assess the efficacy and safety of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in patients with hepatitis B virus-related hepatocellular carcinoma (HCC).

BACKGROUND

ALPSS allows curative resection of conventionally-unresectable liver tumors. However, its role in HCC is largely unknown.

METHODS

Consecutive HCC patients who underwent ALPPS at our center between April 2013 and September 2017 were retrospectively studied. The oncological results were compared with patients receiving transcatheter arterial chemoembolization (TACE), and patients undergoing one-stage resection by using propensity score matching (PSM) analysis.

RESULTS

The median tumor diameter was 13 cm (range: 6-22 cm) in patients with a single tumor (n = 28), whereas the median total tumor diameter was 12 cm (range: 9-31 cm) in patients with multiple tumors (n = 17). After stage-1 ALPPS, the median future liver remnant (FLR) increased by 56.8%. The stage-2 ALPPS was completed in 41 patients (91.1%) after a median of 12 days. The 90-day mortality rate was 11.1% (5/45). The overall survival (OS) rates at 1- and 3-year were 64.2% and 60.2%, whereas the disease-free survival (DFS) rates at 1 and 3 years were 47.6% and 43.9%, respectively. On PSM analysis, the long-term survival of patients undergoing ALPPS was significantly better than those receiving TACE (OS, P = 0.004; DFS, P < 0.0001) and similar to those subjected to one-stage liver resection (OS, P = 0.514; DFS, P = 0.849).

CONCLUSIONS

The long-term survival after ALPPS was significantly better than TACE, and similar to those after one-stage liver resection. ALPPS is a viable treatment option for patients with unresectable HCC in selected patients.

Percutaneous radiofrequency-assisted liver partition versus portal vein embolization before hepatectomy for perihilar cholangiocarcinoma

Background

Percutaneous radiofrequency‐assisted liver partition with portal vein embolization in staged liver resection (PRALPPS) represents an alternative to portal vein embolization (PVE) followed by major liver resection in patients with perihilar cholangiocarcinoma.

Methods

This was an observational case–control study. Both procedures were applied in patients with a future liver remnant (FLR) volume of less than 40 per cent. The main end points of the study were short‐term morbidity and mortality for the two procedures. The study also compared the efficacy of the preresection phases estimated by kinetic growth rate (KGR), time interval and degree of hypertrophy of the FLR.

Results

The first phase (preresection) was completed in 11 and 18 patients, and the second phase (resection) in nine and 14 patients, in the PRALPPS and PVE groups respectively. Major morbidity after the first stage did not differ between the groups. There were no differences in blood loss, severe morbidity or liver failure rate after the second stage, with no deaths. The mean KGR of the FLR after the preresection phase for PRALPPS was 3·8 (0·6–9·8) per cent/day, and that after PVE was 1·8 (0–6·7) per cent/day (P = 0·037). The mean time interval for FLR hypertrophy in the PRALPPS and PVE groups was 15 (6–29) and 20 (8–35) days respectively (P = 0·039).

Conclusion

Short‐term outcomes were similar for PRALPPS and PVE in terms of safety. Remnant hypertrophy was achieved more rapidly by PRALPPS.

ALPPS Improves Resectability Compared With Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastasis: Results From a Scandinavian Multicenter Randomized Controlled Trial (LIGRO Trial)

Objective:

The aim of the study was to evaluate if associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) could increase resection rates (RRs) compared with two-stage hepatectomy (TSH) in a randomized controlled trial (RCT).

Background:

Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails due to insufficient liver growth or tumor progression.

Methods:

A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of less than 30%. Primary outcome—RRs were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality, and 90-day mortality measured from the final intervention.

Results:

Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% [95% confidence interval (CI) 84%–100%] (44/48) in the ALPPS arm compared with 57% (95% CI 43%–72%) (28/49) in the TSH arm [rate ratio 8.25 (95% CI 2.6–26.6); P < 0.0001]. No differences in complications (Clavien–Dindo ≥3a) [43% (19/44) vs 43% (12/28)] [1.01 (95% CI 0.4–2.6); P = 0.99], 90-day mortality [8.3% (4/48) vs 6.1% (3/49)] [1.39 [95% CI 0.3–6.6]; P = 0.68] or R0 RRs [77% (34/44) vs 57% (16/28)] [2.55 [95% CI 0.9–7.1]; P = 0.11)] were observed. Of the patients in the TSH arm that failed to reach an sFLR of 30%, 12 were successfully treated with ALPPS.

Conclusion:

ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications, and short-term mortality.

Dealing with insufficient liver remnant: Associating liver partition and portal vein ligation for staged hepatectomy

Liver resection for colorectal liver metastases has emerged to highly successful treatment in the last decades. Key to this success is complete hepatic tumor removal and systemic disease control by chemotherapy. Associating liver partition and portal vein ligation for staged hepatectomy is the most recent two-stage resection strategy for patients with very small future liver remnant making complete tumor removal possible within 1 to 2 weeks. Oncological outcome data are being collected at the moment and first results from small series reveal promising results.

Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China (2017 Edition)

BACKGROUND

Hepatocellular carcinoma (HCC) (about 85-90% of primary liver cancer) is particularly prevalent in China because of the high prevalence of chronic hepatitis B infection. HCC is the fourth most common malignancy and the third leading cause of tumor-related deaths in China. It poses a significant threat to the life and health of Chinese people.

SUMMARY

This guideline presents official recommendations of the National Health and Family Planning Commission of the People's Republic of China on the surveillance, diagnosis, staging, and treatment of HCC occurring in China. The guideline was written by more than 50 experts in the field of HCC in China (including liver surgeons, medical oncologists, hepatologists, interventional radiologists, and diagnostic radiologists) on the basis of recent evidence and expert opinions, balance of benefits and harms, cost-benefit strategies, and other clinical considerations.

KEY MESSAGES

The guideline presents the Chinese staging system, and recommendations regarding patients with HCC in China to ensure optimum patient outcomes.

Associating Liver Partition and Portal vein ligation for Staged hepatectomy procedure using ischemic bipartition: Two case reports

RATIONALE

The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure is a recently introduced treatment strategy for patients with advanced primary or metastatic liver tumors and small future liver remnants. ALPPS procedure using ischemic bipartition of the liver is a modified technique that may reduce complications compared to classical ALPPS.

PATIENT CONCERNS

Two patients with multiple colorectal liver metastasis with extensive involvement of the liver were considered unresectable before treatment because of small future liver remnant (FLR).

DIAGNOSES

Two patients were diagnosed by imaging examination with volumetry of the liver.

INTERVENTIONS

In the first stage, ischemic bipartition of the liver is achieved using radiofrequency ablation. The Glissonian pedicles from Segment 4 are identified and ablated, the FLR is cleared, and the right portal vein is ligated. In the second stage, the typical procedure is performed, and an extended liver resection is performed.

OUTCOMES

The procedure was feasible with acceptable hypertrophy of FLRs. Blood transfusions were unnecessary, and severe postoperative complications were avoided.

LESSONS

The ALPPS procedure with ischemic bipartition is safe and feasible and can produce results that are the same as those of the classical ALPPS procedure while reducing invasiveness during the first stage.

Tourniquet-ALPPS is a promising treatment for very large hepatocellular carcinoma and intrahepatic cholangiocarcinoma

When very large hepatocellular carcinomas (HCCs) and intrahepatic cholangiocarcinoma (IHCCs) with insufficient future liver remnants are treated using associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), the outcome is often poor. We therefore tested the efficacy of a modified version of that technique, tourniquet-ALPPS. A review of the literature examining outcomes of HCC and IHCC patients treated with ALPPS revealed the incidences of morbidity ≥ III and postoperative mortality to be respectively 20.7% and 16.1% among HCC patients and 50% and 45.4% among IHCC patients. In the present case series, in which HCC and IHCC patients were treated with tourniquet-ALPPS, median tumor size was 100 mm (range: 70–200 mm). After surgical stage I, there was no morbidity, no mortality and the median future liver remnant had increased at day 7 by 76%. In surgical stage II, 100% of tumors were resectable (8 right trisectionectomies, 5 with inferior vena cava resection). Two patients experienced serious morbidity ≥ IIIB and 1 patient died (11%). One- and 3-year overall survival was 75% and 60%, respectively. Thus tourniquet-ALPPS appears to be an effective alternative to classical ALPPS for the treatment of patients with HCC or IHCC.

Feasibility of Percutaneous Intrahepatic Split by Microwave Ablation (PISA) After Portal Vein Embolization for Hypertrophy of Future Liver Remnant: The Radiological Stage-1 ALPPS

PURPOSE

To assess the feasibility of radiological stage-1 ALPPS, associating liver partition and portal vein ligation for staged hepatectomy, by combining portal vein embolization (PVE) with percutaneous intrahepatic split by ablation (PISA).

MATERIALS AND METHODS

Three patients (mean age 65.0 ± 7.3 years) underwent PVE and PISA. PISA was performed 21 days after PVE by microwave ablation to create a continuous intrahepatic cutting plane. Abdominal CT examinations were performed before and after PVE and PISA. The future liver remnant (FLR) volume was calculated by semiautomatic segmentation, and increase was reported as a percentage of the pre-procedural volume. The FLR/body weight (FLR/BW) ratio was calculated; a ratio greater than 0.8% was considered sufficient for guaranteeing adequate liver function after surgery. The liver function before and after PISA was also evaluated by 99mTc-mebrofenin hepatobiliary scintigraphy. Patients' laboratory tests, performance status, ability to walk were assessed before and after PVE and PISA procedures.

RESULTS

No procedure-related complications were recorded. The FLR volume increase in each patient was 42.0, 33.1 and 30.4% within 21 days of PVE and 109.3, 68.1 and 71.7% within 10 days after PISA. The FLR/BW ratios were 0.76, 0.66, 0.63% and 1.13, 0.83, 0.83% after PVE and PISA procedures, respectively. Two patients underwent successful right hepatectomy; in one patient, despite 1.13% FLR/BW, surgery was not performed because of the absolute rejection of blood transfusion due to the patient's religious convictions.

CONCLUSION

Radiological stage-1 ALPPS is a feasible, minimally invasive option to be further investigated to become an effective alternative to surgical stage-1 ALPPS.

Percutaneous microwave ablation liver partition and portal vein embolization for planned hepatectomy due to large gastrointestinal stromal tumor metastases: A case report

RATIONALE

The liver is the most frequent site of relapse of gastrointestinal stromal tumors (GISTs). Surgery is always considered to be unsuitable because of the multiple metastases.

PATIENT CONCERNS

In this report, we describe a case of large, multiple GIST liver metastases that were treated with percutaneous microwave ablation liver partition and portal vein embolization for planned hepatectomy (PALPP). A 44-year-old woman had undergone pancreaticoduodenectomy 4 years previously because of the diagnosis of a large duodenal GIST. Large, multiple liver metastases were observed 2 years later.

DIAGNOSES

GIST liver metastasis was diagnosed using percutaneous ultrasound-guided biopsy.

INTERVENTIONS

After 6 months of treatment with imatinib, the liver metastasis was stable. PALPP was performed because of insufficient future liver remnant (FLR) and right trisegmentectomy was successfully completed 10 days later.

OUTCOMES

The patient has had no signs of local or systemic disease during 17 months of postsurgical follow-up.

LESSONS

PALPP provides a new methodology for treatment of GIST liver metastasis in patients with insufficient FLR, and may have benefit in prolonging a durable remission.

Modifications of ALPPS - from complex to more complex or from complex to less complex operations

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy to reduce the chance of post-hepatectomy liver failure in patients with borderline or insufficient future liver remnant. ALPPS is still in an early developmental stage and its techniques have not been standardized. This study aimed to review the technical modifications of the conventional ALPPS procedure.

DATA SOURCES

Studies were identified by searching MEDLINE and PubMed for articles published from January 2007 to December 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional articles were identified by a manual search of references from key articles.

RESULTS

There have been a lot of modifications of the conventional ALPPS. These are classified as: (1) modifications aiming to improve surgical results; (2) modifications aiming to expand surgical indications; (3) salvage ALPPS; (4) ALPPS using the minimally invasive approach. Some of these modifications have made the conventional ALPPS procedure to become even more complex, although there have also been other attempts to make the procedure less complex. The results of most of these modifications have been reported in small case series or case reports. We need better well-designed studies to establish the true roles of these modifications. However, it is interesting to see how this conventional ALPPS procedure has evolved since its introduction.

CONCLUSIONS

There is a trend for the use of minimally invasive procedure in the phase 1 or 2 of the conventional ALPPS procedure. Some of these modifications have expanded the use of ALPPS in patients who have been considered to have unresectable liver tumors. The long-term oncological outcomes of these modifications are still unknown.

Salvage transhepatic arterial embolization after failed stage I ALPPS in a patient with a huge HCC with chronic liver disease: A case report

•

The arterial supply of the future liver remnant (FLR) may be important for the FLR growth.

•

Huge hepatocellular carcinoma (HCC) can cause blood-stream steal from the FLR, which can result in ALPPS failure.

•

Transarterial embolization (TAE) of HCC can salvage failed Stage I ALPPS.

•

TAE can induce significant hypertrophy of FLR.

•

TAE-salvaged ALPPS may be suitable for huge HCC with chronic liver disease.

Introduction

The degree of hypertrophy of the future liver remnant (FLR) induced by associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in patients with HCC and chronic liver disease is often limited as compared with patients with a healthy liver.

Presentation of case

We reported a 53-year-old male who had a huge HCC (14.8 × 12 × 9.4 cm) arising from a background of hepatitis B liver fibrosis (METAVIR score F3). The ratio of the FLR/standard liver volume (SLV) was 23.8%. After stage I ALPPS, volumetric assessment on postoperative day (POD) 7 and 13 showed insufficient FLR hypertrophy (FLR/SLV: 28.7% and 30.7%, respectively). A postoperative computed tomographic 3D reconstruction and hepatic angiography showed steal of arterial blood from the FLR to the huge tumour in the right liver. Salvage transhepatic arterial embolization (TAE) was performed to block the major arterial blood supply to the tumour on POD 13. The FLR/SLV increased to 42.5% in 7 days. Stage II ALPPS consisting of right trisectionectomy was successfully performed.

Discussion

Salvage TAE which blocked the main arterial blood supply to the huge HCC improved the arterial supply with subsequent adequate and fast hypertrophy of the FLR to allow trisectionectomy in stage II ALPPS to be carried out.

Conclusion

Salvage TAE after failed stage I ALPPS with inadequate hypertrophy of the FLR allowed trisectionectomy in stage II ALPPS to be carried out in a patient with a huge HCC with chronic liver disease.

Evolution of associating liver partition and portal vein ligation for staged hepatectomy: Simpler, safer and equally effective methods

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently demonstrated as a method to induce rapid and extensive hypertrophy within a short time and has been employed for a variety of primary and metastatic liver tumors. However, controversies remain due to its high morbidity and mortality. To enable safer surgery, liver surgeons have searched for better technical modifications, such as partial ALPPS, mini-ALPPS, minimally invasive ALPPS, and Terminal branches portal vein Embolization Liver Partition for Planned hepatectomy (TELPP). It seems that TELPP is very promising, because it has the main advantage of ALPPS - the rapid increase of future liver remnant volume, but the morbidity and mortality are much lower because only one surgical operation is required.

Associating liver partition and portal vein ligation for staged hepatectomy: the current role and development

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient future liver remnant (FLR). ALPPS is still considered to be in an early developmental phase because surgical indications and techniques have not been standardized. This article aimed to review the current role and future developments of ALPPS.

DATA SOURCES

Studies were identified by searching MEDLINE and PubMed for articles from January 2007 to October 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional papers were identified by a manual search of references from key articles.

RESULTS

ALPPS induces more hypertrophy of the FLR in less time than portal vein embolization or portal vein ligation. The benefits of ALPPS include rapid hypertrophy 47%-110% of the liver over a median of 6-16.4 days, and 95%-100% completion rate of the second stage of ALPPS. The main criticisms of ALPPS are centered on its high morbidity and mortality rates. Morbidity rates after ALPPS have been reported to be 15.3%-100%, with ≥ the Clavien-Dindo grade III morbidity of 13.6%-44%. Mortality rates have been reported to be 0%-29%. The important questions to ask even if oncologic long-term results are acceptable are: whether the gain in quality and quantity of life can be off balance by the substantial risks of morbidity and mortality, and whether stimulation of rapid liver hypertrophy also accelerates rapid tumor progression and spread. Up till now, the documentations of the ALPPS procedure come mainly from case series, and most of these series include heterogeneous groups of malignancies. The numbers are also too small to separately evaluate survival for different tumor etiologies.

CONCLUSIONS

Currently, knowledge on ALPPS is limited, and prospective randomized studies are lacking. From the reported preliminary results, safety of the ALPPS procedure remains questionable. ALPPS should only be used in experienced, high-volume hepatobiliary centers.