Korean J Hepatobiliary Pancreat Surg.  2016 May;20(2):75-80. 10.14701/kjhbps.2016.20.2.75.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure for hepatocellular carcinoma with chronic liver disease: a case report and review of literature

• Papamichail M
• Pizanias M
• Yip V
• Prassas E
• Prachalias A
• Quaglia A
• Peddu P
• Heaton N
• Srinivasan P

• KMID: 2243019
• DOI: http://doi.org/10.14701/kjhbps.2016.20.2.75

Abstract

The incidence of complications after liver resection is closely related to functional future liver remnant (FLR). The standard approach to augment FLR is surgical or radiological occlusion of the artery or portal vein on the tumor side. Associated liver partition and portal vein ligation for staged hepatectomy (ALLPS) has been introduced as an alternative method to augment FLR. It offers rapid and effective hypertrophy for resecting liver metastases. However, data regarding its application in patients with hepatocellular carcinoma (HCC) with a background of chronic liver disease are limited. Here we describe the use of ALPPS procedure to manage a large solitary HCC with a background of chronic liver disease. The rising incidence of HCC has increased the number of surgical resections in patients with advanced stage liver disease not considered for liver transplantation. We reviewed reported experience of ALPPS in established chronic liver disease and current therapeutic modalities for HCC on a background of chronic liver disease in patients with potential liver insufficiency where tumor burden is beyond liver transplant criteria.

Keyword

ALPPS; Liver cirrhosis

MeSH Terms

Arteries
Carcinoma, Hepatocellular*
Hepatectomy*
Hepatic Insufficiency
Humans
Hypertrophy
Incidence
Ligation*
Liver Cirrhosis
Liver Diseases*
Liver Transplantation
Liver*
Neoplasm Metastasis
Portal Vein*
Tumor Burden

Figure

• 

  Fig. 1 Arterial phase CT imaging showing the presence of a lesion lying within the right liver segments V/VIII. It measures up to 8 cm showing enhancement, suggesting hepatocellular carcinoma.

• 

  Fig. 2 CT imaging of lesion post-TACE showing partial response of tumor with small future liver remnant.

• 

  Fig. 3 Changes in aspartate transaminase level.

• 

  Fig. 4 Changes in alkaline phosphatase level.

• 

  Fig. 5 Changes in total bilirubin level.

• 

  Fig. 6 Post-1st stage ALPPS CT imaging showing significant increase in the volume of the future remnant liver.

• 

  Fig. 7 The tumor consisted of a moderately differentiated hepatocellular carcinoma with acinar pattern in this field (H&E, ×200).

• 

  Fig. 8 Background liver showing porto-septal fibrosis with slender and mainly porto-portal septa without parenchymal nodule formation (Gordon and Sweet reticulin staining, ×20).

• 

  Fig. 9 Post-2nd stage ALPPS CT imaging showing adequate increase of the liver remnant.

Reference

1. Ielpo B, Caruso R, Ferri V, Quijano Y, Duran H, Diaz E, et al. ALPPS procedure: our experience and state of the art. Hepatogastroenterology. 2013; 60:2069–2075. PMID: 24719949.

2. Aoki T, Imamura H, Hasegawa K, Matsukura A, Sano K, Sugawara Y, et al. Sequential preoperative arterial and portal venous embolizations in patients with hepatocellular carcinoma. Arch Surg. 2004; 139:766–774. PMID: 15249411.

3. Ogata S, Belghiti J, Farges O, Varma D, Sibert A, Vilgrain V. Sequential arterial and portal vein embolizations before right hepatectomy in patients with cirrhosis and hepatocellular carcinoma. Br J Surg. 2006; 93:1091–1098. PMID: 16779884.

4. Seo DD, Lee HC, Jang MK, Min HJ, Kim KM, Lim YS, 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; 14:3501–3509. PMID: 17899289.

5. De Carlis L, Belli LS, Romani F, Aseni P, Baticci F, Sansalone CV, et al. Selection criteria for liver transplantation: preliminary experience of Niguarda Hospital, Milan. Transplant Proc. 1989; 21:2415–2416. PMID: 2652788.

6. Alvarez FA, Ardiles V, Sanchez Claria R, Pekolj J, de Santibañes E. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): tips and tricks. J Gastrointest Surg. 2013; 17:814–821. PMID: 23188224.

7. Tschuor Ch, Croome KP, Sergeant G, Cano V, Schadde E, Ardiles V, et al. Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion -- an extension of the ALPPS approach. Eur J Surg Oncol. 2013; 39:1230–1235. PMID: 23994139.

8. Vennarecci G, Laurenzi A, Santoro R, Colasanti M, Lepiane P, Ettorre GM. The ALPPS procedure: a surgical option for hepatocellular carcinoma with major vascular invasion. World J Surg. 2014; 38:1498–1503. PMID: 24146197.

9. Schadde E, Ardiles V, Slankamenac K, Tschuor C, Sergeant G, Amacker N, et al. ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors compared with conventional-staged hepatectomies: results of a multicenter analysis. World J Surg. 2014; 38:1510–1519. PMID: 24748319.

10. van Lienden KP, van den Esschert JW, de Graaf W, Bipat S, Lameris JS, van Gulik TM, et al. Portal vein embolization before liver resection: a systematic review. Cardiovasc Intervent Radiol. 2013; 36:25–34. PMID: 22806245.

11. Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, 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; 255:405–414. PMID: 22330038.

12. Nadalin S, Capobianco I, Li J, Girotti P, Königsrainer I, Königsrainer A. 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; 52:35–42. PMID: 24420797.

13. Shindoh J, Vauthey JN, Zimmitti G, Curley SA, Huang SY, Mahvash A, et al. Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach. J Am Coll Surg. 2013; 217:126–133. PMID: 23632095.

14. Zhang GQ, Zhang ZW, Lau WY, Chen XP. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): a new strategy to increase resectability in liver surgery. Int J Surg. 2014; 12:437–441. PMID: 24704086.

15. Shindoh J, D Tzeng CW, Vauthey JN. Portal vein embolization for hepatocellular carcinoma. Liver Cancer. 2012; 1:159–167. PMID: 24159580.

16. Ribero D, Curley SA, Imamura H, Madoff DC, Nagorney DM, Ng KK, et al. Selection for resection of hepatocellular carcinoma and surgical strategy: indications for resection, evaluation of liver function, portal vein embolization, and resection. Ann Surg Oncol. 2008; 15:986–992. PMID: 18236112.

17. Vilgrain V, Sibert A, Zappa M, Belghiti J. Sequential arterial and portal vein embolization in patients with cirrhosis and hepatocellular carcinoma: the hospital beaujon experience. Semin Intervent Radiol. 2008; 25:155–161. PMID: 21326556.

18. Ng KK, Poon RT. Current treatment strategy for hepatocellular carcinoma. Saudi Med J. 2007; 28:1330–1338. PMID: 17768455.

19. Yokoyama Y, Nishio H, Ebata T, Igami T, Sugawara G, Nagino M. Value of indocyanine green clearance of the future liver remnant in predicting outcome after resection for biliary cancer. Br J Surg. 2010; 97:1260–1268. PMID: 20602507.

20. Cucchetti A, Cescon M, Trevisani F, Pinna AD. Current concepts in hepatic resection for hepatocellular carcinoma in cirrhotic patients. World J Gastroenterol. 2012; 18:6398–6408. PMID: 23197885.

21. Vennarecci G, Laurenzi A, Levi Sandri GB, Busi Rizzi E, Cristofaro M, Montalbano M, et al. The ALPPS procedure for hepatocellular carcinoma. Eur J Surg Oncol. 2014; 40:982–988. PMID: 24767805.