Application of anterior approach combined with selective hepatic vein(s) occlusion in ALPPS for giant hepatocellular carcinoma in right lobe (report of 9 cases)_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

XU Banghao ¹ ,  WEN Zhang ¹ , SONG Jingqing ² , YE Chunhui ¹ , ZENG Jingjing ³ , ZHANG Ling ⁴ , TENG Yanjuan ¹ , GUO Ya ¹ , PENG Minhao ¹

1. Department of Hepatobiliary Surgery, The First Affiliated Hospital, Guangxi Medical University, Nanning 530021, P. R. China;
2. Department of General Surgery, The Second People’s Hospital of Qinzhou, Qinzhou, Guangxi 535000, P. R. China;
3. Department of Pathology, The First Affiliated Hospital, Guangxi Medical University, Nanning 530021, P. R. China;
4. Department of Radiology, The First Affiliated Hospital, Guangxi Medical University, Nanning 530021, P. R. China;

Corresponding author：

WEN Zhang, Email: wenzgxmu@163.com

Keywords：

hepatocellular carcinoma; anterior approach; associating liver partition and portal vein ligation for staged hepatectomy; hepatic vein

DOI：

10.7507/1007-9424.201710041

Video：

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Objective To evaluate application of anterior approach combined with selective hepatic vein(s) occlusion in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for giant hepatocellular carcinoma (HCC) in right lobe. Method The clinical data of 9 patients underwent the ALPPS in the First Affiliated Hospital of Guangxi Medical University from January 2017 to September 2017 were retrospectively analyzed. Results Six cases underwent the complete ALPPS, 3 cases lost because it couldn’t match the standard for the second step. After the first step, The average increased volume of the future liver remnant (FLR) was 139.1 cm³ (46.4–291.6 cm³), and the average increased volume rate of FLR was 37.8% (15.1%–76.2%). The average blood loss was 356 mL (200–600 mL). In the second step, 4 cases underwent the right hemihepatectomy and 2 cases underwent the extend right hemihepatectomy, the average blood loss was 617 mL (300–1 400 mL). There was no bile fistula, liver failure, and death. Conclusions Preliminary results of limited cases in this study show that application of anterior approach combined with selective hepatic vein(s) occlusion is a safe and feasible strategy in ALPPS for giant HCC in right lobe. This strategy is conformity with the " no touch” principle of oncology surgery, and reduces blood loss and decreases complications. Long-term oncological result of ALPPS in HCC patients with cirrhosis is unknown.

Citation： XU Banghao, WEN Zhang, SONG Jingqing, YE Chunhui, ZENG Jingjing, ZHANG Ling, TENG Yanjuan, GUO Ya, PENG Minhao. Application of anterior approach combined with selective hepatic vein(s) occlusion in ALPPS for giant hepatocellular carcinoma in right lobe (report of 9 cases). CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2017, 24(12): 1444-1449. doi: 10.7507/1007-9424.201710041 Copy

1.	Ferrero A, Viganò L, Polastri R, et al. Postoperative liver dysfunction and future remnant liver: where is the limit? Results of a prospective study. World J Surg, 2007, 31(8): 1643-1651.
2.	Tucker ON, Heaton N. The ‘small for size’ liver syndrome. Curr Opin Crit Care, 2005, 11(2): 150-155.
3.	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(3): 405-414.
4.	Lau WY, Lai EC. Modifications of ALPPS—from complex to more complex or from complex to less complex operations. Hepatobiliary Pancreat Dis Int, 2017, 16(4): 346-352.
5.	Aloia TA, Vauthey JN. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): what is gained and what is lost? Ann Surg, 2012, 256(3): e9.
6.	Liu CL, Fan ST, Cheung ST, et al. Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study. Ann Surg, 2006, 244(2): 194-203.
7.	Ishizawa T, Kokudo N, Makuuchi M. Right hepatectomy for hepatocellular carcinoma: is the anterior approach superior to the conventional approach? Ann Surg, 2008, 247(2): 390-391.
8.	Ishak K, Baptista A, Bianchi L, et al. Histological grading and staging of chronic hepatitis. J Hepatol, 1995, 22(6): 696-699.
9.	Liver Cancer Study Group of Japan. The general rules for the clinical and pathological study of primary liver cancer. Jpn J Surg, 1989, 19(1): 98-129.
10.	Rahbari NN, Garden J, Padbury R, et al. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery, 2011, 149(5): 713-724.
11.	Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004, 240(2): 205-213.
12.	Moris D, Ronnekleiv-Kelly S, Kostakis ID, et al. Operative results and oncologic outcomes of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) versus two-stage hepatectomy (TSH) in patients with unresectable colorectal liver metastases: a systematic review and meta-analysis. World J Surg, 2017 Aug 10. doi: 10.1007/s00268-017-4181-6. [Epub ahead of print].
13.	Tanaka K. Modified ALPPS procedures: more safety through less invasive surgery. Langenbecks Arch Surg, 2017, 402(4): 563-574.
14.	彭驰涵, 李川, 文天夫, 等. 原发性肝癌行 ALPPS 的适应证与禁忌证初探(附 15 例报道). 中国普外基础与临床杂志, 2015, 22(10): 1183-1186.
15.	Alvarez FA, Ardiles V, Sanchez Claria R, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): tips and tricks. J Gastrointest Surg, 2013, 17(4): 814-821.
16.	Alvarez FA, Iniesta J, Lastiri J, et al. New method of hepatic regeneration. Cir Esp, 2011, 89(10): 645-649.
17.	Nadalin S, Capobianco I, Li J, et al. Indications and limits for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Lessons Learned from 15 cases at a single centre. Z Gastroenterol, 2014, 52(1): 35-42.
18.	Edmondson MJ, Sodergren MH, Pucher PH, et al. Variations and adaptations of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS): Many routes to the summit. Surgery, 2016, 159(4): 1058-1072.
19.	Cai X, Tong Y, Yu H, et al. The ALPPS in the treatment of hepatitis B-related hepatocellular carcinoma with cirrhosis: a single-center study and literature review. Surg Innov, 2017, 24(4): 358-364.
20.	Alvarez FA, Ardiles V, de Santibañes M, et al. Associating liver partition and portal vein ligation for staged hepatectomy offers high oncological feasibility with adequate patient safety: a prospective study at a single center. Ann Surg, 2015, 261(4): 723-732.
21.	Schadde E, Schnitzbauer AA, Tschuor C, et al. Systematic review and meta-analysis of feasibility, safety, and efficacy of a novel procedure: associating liver partition and portal vein ligation for staged hepatectomy. Ann Surg Oncol, 2015, 22(9): 3109-3120.
22.	Li J, Girotti P, Königsrainer I, et al. ALPPS in right trisectionectomy: a safe procedure to avoid postoperative liver failure? J Gastrointest Surg, 2013, 17(5): 956-961.
23.	Vivarelli M, Vincenzi P, Montalti R, et al. ALPPS procedure for extended liver resections: a single centre experience and a systematic review. PLoS One, 2015, 10(12): e0144019.
24.	. Lai EC, Fan ST, Lo CM, et al. Anterior approach for difficult major right hepatectomy. World J Surg, 1996, 20(3): 314-318.
25.	Belghiti J, Guevara OA, Noun R, et al. Liver hanging maneuver: a safe approach to right hepatectomy without liver mobilization. J Am Coll Surg, 2001, 193(1): 109-111.
26.	Hao S, Chen S, Tu C, et al. Anterior approach to improve the prognosis in HCC patients via decreasing dissemination of EpCAM⁺ circulating tumor cells. J Gastrointest Surg, 2017, 21(7): 1112-1120.
27.	Yang Y, Lai EC, Fu SY, et al. A prospective randomized controlled trial to compare two methods of selective hepatic vascular exclusion in partial hepatectomy. Eur J Surg Oncol, 2013, 39(2): 125-130.
28.	Yang Y, Zhao LH, Fu SY, et al. Selective hepatic vascular exclusion versus pringle maneuver in partial hepatectomy for liver hemangioma compressing or involving the major hepatic veins. Am Surg, 2014, 80(3): 236-240.

1. Ferrero A, Viganò L, Polastri R, et al. Postoperative liver dysfunction and future remnant liver: where is the limit? Results of a prospective study. World J Surg, 2007, 31(8): 1643-1651.
2. Tucker ON, Heaton N. The ‘small for size’ liver syndrome. Curr Opin Crit Care, 2005, 11(2): 150-155.
3. 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(3): 405-414.
4. Lau WY, Lai EC. Modifications of ALPPS—from complex to more complex or from complex to less complex operations. Hepatobiliary Pancreat Dis Int, 2017, 16(4): 346-352.
5. Aloia TA, Vauthey JN. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): what is gained and what is lost? Ann Surg, 2012, 256(3): e9.
6. Liu CL, Fan ST, Cheung ST, et al. Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study. Ann Surg, 2006, 244(2): 194-203.
7. Ishizawa T, Kokudo N, Makuuchi M. Right hepatectomy for hepatocellular carcinoma: is the anterior approach superior to the conventional approach? Ann Surg, 2008, 247(2): 390-391.
8. Ishak K, Baptista A, Bianchi L, et al. Histological grading and staging of chronic hepatitis. J Hepatol, 1995, 22(6): 696-699.
9. Liver Cancer Study Group of Japan. The general rules for the clinical and pathological study of primary liver cancer. Jpn J Surg, 1989, 19(1): 98-129.
10. Rahbari NN, Garden J, Padbury R, et al. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery, 2011, 149(5): 713-724.
11. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004, 240(2): 205-213.
12. Moris D, Ronnekleiv-Kelly S, Kostakis ID, et al. Operative results and oncologic outcomes of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) versus two-stage hepatectomy (TSH) in patients with unresectable colorectal liver metastases: a systematic review and meta-analysis. World J Surg, 2017 Aug 10. doi: 10.1007/s00268-017-4181-6. [Epub ahead of print].
13. Tanaka K. Modified ALPPS procedures: more safety through less invasive surgery. Langenbecks Arch Surg, 2017, 402(4): 563-574.
14. 彭驰涵, 李川, 文天夫, 等. 原发性肝癌行 ALPPS 的适应证与禁忌证初探(附 15 例报道). 中国普外基础与临床杂志, 2015, 22(10): 1183-1186.
15. Alvarez FA, Ardiles V, Sanchez Claria R, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): tips and tricks. J Gastrointest Surg, 2013, 17(4): 814-821.
16. Alvarez FA, Iniesta J, Lastiri J, et al. New method of hepatic regeneration. Cir Esp, 2011, 89(10): 645-649.
17. Nadalin S, Capobianco I, Li J, et al. Indications and limits for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Lessons Learned from 15 cases at a single centre. Z Gastroenterol, 2014, 52(1): 35-42.
18. Edmondson MJ, Sodergren MH, Pucher PH, et al. Variations and adaptations of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS): Many routes to the summit. Surgery, 2016, 159(4): 1058-1072.
19. Cai X, Tong Y, Yu H, et al. The ALPPS in the treatment of hepatitis B-related hepatocellular carcinoma with cirrhosis: a single-center study and literature review. Surg Innov, 2017, 24(4): 358-364.
20. Alvarez FA, Ardiles V, de Santibañes M, et al. Associating liver partition and portal vein ligation for staged hepatectomy offers high oncological feasibility with adequate patient safety: a prospective study at a single center. Ann Surg, 2015, 261(4): 723-732.
21. Schadde E, Schnitzbauer AA, Tschuor C, et al. Systematic review and meta-analysis of feasibility, safety, and efficacy of a novel procedure: associating liver partition and portal vein ligation for staged hepatectomy. Ann Surg Oncol, 2015, 22(9): 3109-3120.
22. Li J, Girotti P, Königsrainer I, et al. ALPPS in right trisectionectomy: a safe procedure to avoid postoperative liver failure? J Gastrointest Surg, 2013, 17(5): 956-961.
23. Vivarelli M, Vincenzi P, Montalti R, et al. ALPPS procedure for extended liver resections: a single centre experience and a systematic review. PLoS One, 2015, 10(12): e0144019.
24. . Lai EC, Fan ST, Lo CM, et al. Anterior approach for difficult major right hepatectomy. World J Surg, 1996, 20(3): 314-318.
25. Belghiti J, Guevara OA, Noun R, et al. Liver hanging maneuver: a safe approach to right hepatectomy without liver mobilization. J Am Coll Surg, 2001, 193(1): 109-111.
26. Hao S, Chen S, Tu C, et al. Anterior approach to improve the prognosis in HCC patients via decreasing dissemination of EpCAM⁺ circulating tumor cells. J Gastrointest Surg, 2017, 21(7): 1112-1120.
27. Yang Y, Lai EC, Fu SY, et al. A prospective randomized controlled trial to compare two methods of selective hepatic vascular exclusion in partial hepatectomy. Eur J Surg Oncol, 2013, 39(2): 125-130.
28. Yang Y, Zhao LH, Fu SY, et al. Selective hepatic vascular exclusion versus pringle maneuver in partial hepatectomy for liver hemangioma compressing or involving the major hepatic veins. Am Surg, 2014, 80(3): 236-240.

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Application of anterior approach combined with selective hepatic vein(s) occlusion in ALPPS for giant hepatocellular carcinoma in right lobe (report of 9 cases)

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