Application of associating liver partition and portal vein ligation for staged hepatectomy for initially unresectable hepatocellular carcinoma

Abstract

Objective To evaluate the safety and efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in the treatment of initially unresectable hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and to preliminarily explore the mechanism of rapid growth of the future liver remnant (FLR). Methods Twenty-four patients with HBV-associated HCC who underwent ALPPS in our hospital from August 2014 to January 2021 were retrospectively studied. Propensity score matching was used to compare oncologic outcomes of patients treated with ALPPS and transarterial chemoembolization (TACE). The expression of YAP and JNK in liver tissue after two stages of ALPPS were detected. Results The median standard liver volume (SLV) was 1471.4 ml. Before second stage of ALPPS, the median FLR increased by 74.4%, and the median FLR/SLV increased from 26.1 to 41.6%. Twenty-two patients (91.7%) received staged hepatectomy after a median interval of 15 (9–24) d. The total incidence of postoperative complications in ALPPS group was 54.5%, and of Clavien–Dindo ≥ IIIb postoperative complications (requiring surgical, endoscopic or radiological intervention under general anesthesia) was 9.1%. There was no significant difference in total complications between ALPPS group and TACE group, but there were lower rate of above grade III complications in the TACE group than that in the ALPPS group. The incidence of complications was lower in laparoscopic-ALPPS than that in open surgery. In ALPPS group, the 1-year, 2-year and 5-year overall survival rate were respectively 71.4%, 33.3% and 4.8%. Interval time was an independent risk factor associated with overall survival rate. There was no significant difference in overall survival rate between ALPPS group and TACE group. For advanced HCC (BCLC stage B and C), ALPPS group was not superior to TACE group in overall survival rate. The expression of YAP and p-JNK in the residual liver tissue after second stage procedure was higher than that after first stage procedure, and the co-expression of YAP and p-JNK was observed in the residual liver tissue. Conclusion ALPPS is a safe and effective treatment for initially unresectable HBV-associated HCC. Laparoscopic technique might improve the effect of ALPPS. YAP and JNK pathway might take a role in rapid FLR increase in ALPPS procedure.

Current Trends in Surgical Management of Hepatocellular Carcinoma

“…A recent study by Chen et al investigated the effectiveness of ALPPS in HCC patients, with an average growth of 59% after a mean of 16 days, with almost 92% of the patients completing the second stage [71]. In a clinical trial comparing ALPPS to PVE in hepatitisrelated HCC, ALPPS induced a 49% increase in FLR volume, and patients required a median of 7.5 days until the second stage could be performed [67].…”

“…Despite studies showing variable outcomes, it is undeniable that a major limitation of ALPPS is its associated morbitidy rates [71,72]. This prompted the development of minimally invasive (MI) approaches due to the well-known benefits of laparoscopic or robotic techniques (further discussed in Section 4.1.3).…”