Abstract
Background
Extended liver resections in patients with hepatocellular carcinoma (HCC) are problematic due to hepatitis, fibrosis, and cirrhosis. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been promoted as a novel method to induce hypertrophy for patients with extensive colorectal liver metastases, but outcomes in HCC have not been well investigated.
Methods
All patients registered in the international ALPPS Registry (www.alpps.org) from 2010 to 2015 were studied. Hypertrophy of the future liver remnant, perioperative morbidity and mortality, age, overall survival, and other parameters were compared between patients with HCC and patients with colorectal liver metastases (CRLM).
Results
The study compared 35 patients with HCC and 225 patients with CRLM. The majority of patients undergoing ALPPS for HCC fall into the intermediate-stage category of the Barcelona clinic algorithm. In this study, hypertrophy was rapid and extensive for the HCC patients, albeit lower than for the CRLM patients (47 vs. 76 %; p < 0.002). Hypertrophy showed a linear negative correlation with the degrees of fibrosis. The 90-day mortality for ALPPS used to treat HCC was almost fivefold higher than for CRLM (31 vs. 7 %; p < 0.001). Multivariate analysis showed that patients older than 61 years had a significantly reduced overall survival (p < 0.004).
Conclusion
The ALPPS approach induces a considerable hypertrophic response in HCC patients and allows resection of intermediate-stage HCC, albeit at the cost of a 31 % perioperative mortality rate. The use of ALPPS for HCC remains prohibitive for most patients and should be performed only for a highly selected patient population younger than 60 years with low-grade fibrosis.
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References
Agrawal S, Belghiti J. Oncologic resection for malignant tumors of the liver. Ann Surg. 2011;253:656–65.
Schnitzbauer AA, Lang SA, Goessmann H, et al. 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;255:405–14.
de Santibanes E, Clavien PA. Playing Play-Doh to prevent postoperative liver failure: the “ALPPS” approach. Ann Surg. 2012;255:415–7.
Wicherts DA, Miller R, de Haas RJ, et al. Long-term results of two-stage hepatectomy for irresectable colorectal cancer liver metastases. Ann Surg. 2008;248:994–1005.
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;240:1037–49; discussion 1049–51
Wicherts DA, de Haas RJ, Andreani P, et al. Impact of portal vein embolization on long-term survival of patients with primarily unresectable colorectal liver metastases. Br J Surg. Feb 2010;97(2):240–250.
Abulkhir A, Limongelli P, Healey AJ, et al. Preoperative portal vein embolization for major liver resection: a meta-analysis. Ann Surg. 2008;247:49–57.
Schadde E, Ardiles V, Robles-Campos R, et al. Early survival and safety of ALPPS: first report of the International ALPPS Registry. Ann Surg. 2014;260:829–36; discussion 836–828
Li J, Girotti P, Konigsrainer I, Ladurner R, Konigsrainer A, Nadalin S. ALPPS in right trisectionectomy: a safe procedure to avoid postoperative liver failure? J Gastrointest Surg. 2013;17:956–61.
Knoefel WT, Gabor I, Rehders A, et al. In situ liver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection. Br J Surg. 2013;100:388–94.
Torres OJ, Fernandes Ede S, Oliveira CV, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): the Brazilian experience. ABCD Braz Arch Dig Surg. 2013;26:40–3.
Chia NH, Lai EC, Lau WY. Associating liver partition and portal vein ligation for a patient with hepatocellular carcinoma with a background of hepatitis B related fibrotic liver. Int J Surg Case Rep. 2014;5:1077–81.
Vennarecci G, Laurenzi A, Levi Sandri GB, et al. The ALPPS procedure for hepatocellular carcinoma. Eur J Surg Oncol. 2014. doi:10.1016/j.ejso.2014.04.002.
Xiao L, Li JW, Zheng SG. Totally laparoscopic ALPPS in the treatment of cirrhotic hepatocellular carcinoma. Surg Endosc. 2014. doi:10.1007/s00464-014-4000-1.
Chan AC, Pang R, Poon RT. Simplifying the ALPPS procedure by the anterior approach. Ann Surg. 2014;260:e3.
Vauthey JN, Abdalla EK, Doherty DA, et al. Body surface area and body weight predict total liver volume in Western adults. Liver Transpl. 2002;8:233–40.
Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96.
Balzan S, Belghiti J, Farges O, et al. The “50-50 criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg. 2005;242:824–8; discussion 828–9.
Desmet VJ, Gerber M, Hoofnagle JH, Manns M, Scheuer PJ. Classification of chronic hepatitis: diagnosis, grading and staging. Hepatol Baltimore Md 1994;19:1513–20.
van Lienden KP, van den Esschert JW, de Graaf W, et al. Portal vein embolization before liver resection: a systematic review. Cardiovasc Intervent Radiol. 2013;36:25–34.
Li J, Kantas A, Ittrich H, et al. Avoid “all-touch” by hybrid ALPPS to achieve oncological efficacy. Ann Surg. 2014. doi:10.1097/SLA.0000000000000845.
Petrowsky H, Gyori G, de Oliveira M, Lesurtel M, Clavien PA. Is partial ALPPS safer than ALPPS? A single-center experience. Ann Surg. 2015;261:e90–2.
Gall TM, Sodergren MH, Frampton AE, et al. Radiofrequency-assisted liver partition with portal vein ligation (RALPP) for liver regeneration. Ann Surg. 2015;261:e45–6.
Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg. 2001;234:507–17; discussion 517–509.
Forner A, Llovet JM, Bruix J. Hepatocellular carcinoma. Lancet. 2012;379:1245–55.
Azoulay D, Castaing D, Krissat J, et al. Percutaneous portal vein embolization increases the feasibility and safety of major liver resection for hepatocellular carcinoma in injured liver. Ann Surg. 2000;232:665–72.
Tanaka H, Hirohashi K, Kubo S, Shuto T, Higaki I, Kinoshita H. Preoperative portal vein embolization improves prognosis after right hepatectomy for hepatocellular carcinoma in patients with impaired hepatic function. Br J Surg. 2000;87:879–82.
Wakabayashi H, Ishimura K, Okano K, et al. Is preoperative portal vein embolization effective in improving prognosis after major hepatic resection in patients with advanced-stage hepatocellular carcinoma? Cancer. 2001;92:2384–90.
Palavecino M, Chun YS, Madoff DC, et al. Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: perioperative outcome and survival. Surgery. 2009;145:399–405.
Seo DD, Lee HC, Jang MK, et al. Preoperative portal vein embolization and surgical resection in patients with hepatocellular carcinoma and small future liver remnant volume: comparison with transarterial chemoembolization. Ann Surg Oncol 2007;14:3501–9.
Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med. 1996;334:693–9.
Ismail T, Angrisani L, Gunson BK, et al. Primary hepatic malignancy: the role of liver transplantation. Br J Surg. 1990;77:983–7.
Chan AC, Poon RT, Chan SC, Lo CM. Safety of ALPPS procedure by the anterior approach for hepatocellular carcinoma. Ann Surg. 2015.
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E. Schadde and M. K. Angele have contributed equally to this work.
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D’Haese, J.G., Neumann, J., Weniger, M. et al. Should ALPPS be Used for Liver Resection in Intermediate-Stage HCC?. Ann Surg Oncol 23, 1335–1343 (2016). https://doi.org/10.1245/s10434-015-5007-0
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DOI: https://doi.org/10.1245/s10434-015-5007-0