Abstract: Objective:To investigate the safety and clinical effect of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in the treatment of hepatocellular carcinoma (HCC) with cirrhosis.
Methods:The retrospective cohort study was adopted. The clinical data of 5 patients with primary HCC with cirrhosis who underwent ALPPS at the First Bethune Hospital of Jilin University between October 2014 and August 2015 were collected. The surgical plan was determined according to preoperative liver function and liver functional reserve. The patients underwent portal vein (PV) ligation and liver partition in the first staged surgery. The second staged surgery was performed when growing future live remnant (FLR) came up to the standard of safe section by rescan of computed tomography (CT) at 10, 14, 18 days after the first staged surgery, and hemihepatectomy and hepatic segmentectomy were applied to patients. (1) The intraoperative situations were observed, including the severity of liver cirrhosis, first staged surgery time, volume of intraoperative blood loss and FLR in the first staged surgery, interval time of surgery, growth rate of liver volume, ratio of FLR and standard liver volume (SLV), time and volume of intraoperative blood loss in the second staged surgery. (2) Pre and postoperative biochemical indicators in the first and second staged surgeries were detected, including total bilirubin (TBil) and alanine phosphatase (ALT). (3) Postoperative situations were observed, including occurrence of complications, results of pathological examination and duration of hospital stay. (4) The followup using telephone reservation and outpatient examination was performed to detect tumors recurrence and metastasis and survival of patients by imaging examination and tumor marker test up to November 2015. Count data were represented as mean (range).
Results:(1) Intraoperative situations: of 5 patients, there were 1 patient with F3 of liver cirrhosis and 4 with F4 of liver cirrhosis. One patient was complicated with lots of peritoneal effusion, followed by acute renal failure, and didn't receive the second staged surgery. Four patients underwent successful ALPPS. The first staged surgery of 5 patients: average operation time, volume of intraoperative blood loss, FLR, interval time of surgery, growth rate of liver volume, ratio of FLR and SLV were 282 minutes (range, 240-320 minutes), 500 mL (range, 300-700 mL), 457 cm3 (range, 338-697 cm3), 15 days (range, 14-18 days), 58% (range, 46%-67%) and 42% (range, 32%-44%), respectively. Average operation time and volume of intraoperative blood loss in second staged surgery were 220 minutes (range, 200-260 minutes) and 412 mL (range, 300-600 mL). (2) Pre and postoperative biochemical indicators: levels of TBil and ALT of 5 patients from preoperation to postoperative day 12 in the first staged surgery were from 4.9-30.4 μmol/L to 9.8-56.1 μmol/L and from 12.9-156.1 U/L to 46.3-207.3 U/L, respectively. Levels of TBil and ALT of 4 patients from preoperation to postoperative day 10 in the second staged surgery were from 10.1-21.2μmol/L to 6.9-38.0 μmol/L and from 30.8-55.5 U/L to 19.8-72.8 U/L, respectively. (3) Postoperative situations: there were no perioperative death and postoperative complications of liver failure and intraperitoneal infection. One patient complicated with bile leakage was cured by nonoperative treatment for 30 days. Results of pathological examination: 5 patients were confirmed asⅡ-Ⅲ stage HCC, and 4 tumors had vascular tumor thrombi and negative resection margin with tumor size of 8-13 cm. Duration of hospital stay of 5 patients was 36 days (range,28-48 days). (4) Results of followup: 4 patients undergoing successful ALPPS were followed up for 4-12 months. One patient was emerged with a new lesion of 2 cm in left half liver at postoperative month 7, level of AFP of which was 512 μg/L before the first staged surgery reduced to normal level at postoperative month 2, and then the patient received transcatheter arterial chemoembolization (TACE) and radio frequency ablation (RFA) treatments without tumor recurrence up to postoperative month 12. No tumor recurrence and new lesions in liver were detected in other 3 patients by abdominal enhanced scan of CT, with a normal level of AFP.
Conclusion:ALPPS is safe and feasible for HCC with cirrhosis, with a satisfactory short-term outcome.