Case Report: The application of associating liver partition and portal vein ligation for staged hepatectomy in patients with hepatitis b virus-related hepatocellular carcinoma after undergoing treatment with an immune checkpoint inhibitor: a report of two cases

Hepatocellular carcinoma (HCC) is often diagnosed at an unresectable stage without opportunities for curative therapy. Future liver remnant (FLR) insufficiency limits the range of patients who can undergo radical resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can ultimately achieve short-term hypertrophy of the FLR in patients with viral hepatitis-related fibrosis/cirrhosis and R0 resection. However, the influence of immune checkpoint inhibitors (ICIs) on liver regeneration remains unknown. We report two patients diagnosed with Barcelona Clinic Liver Cancer (BCLC)-B stage hepatitis B virus (HBV)-related HCC who underwent pioneering ALPPS after immunotherapy without posthepatectomy liver failure (PHLF). ALPPS has been shown to be safe and feasible in patients with HCC who underwent immunotherapy previously for the first time and might provide an alternative salvage option for future conversion therapy of HCC.

Recent advances in surgical strategies and liver transplantation for hepatoblastoma

Hepatoblastoma (HB) is the most common malignant liver tumor in children. Although the development of treatment strategies with advances in chemotherapy has greatly improved the prognosis of HB, surgical resection and liver transplantation still play a vital role in the treatment of HB. In recent years, technological innovations have led to the development of new surgical approaches for HB. In this review, we describe the latest research on the surgical management of HB, including new imaging technologies, minimally invasive approaches, and the application of associating liver partition portal vein ligation for staged hepatectomy. We also discuss the current role of liver transplantation, use of ante-situm or ex-situ liver resection with auto-transplantation, and management of metastatic HB.

A case report of tumor lysis syndrome after stage-one ALPPS

RATIONALE

Tumor lysis syndrome is a potentially lethal condition caused by rapid cell death, releasing a high level of toxic cytokines. It is common in patients with hematological malignancy but rare in solid tumors.

PATIENT CONCERNS

A 64-year-old patient presented to our unit with a 17.3-cm hepatocellular carcinoma and marginal liver reserve. The first-stage operation of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was performed.

DIAGNOSIS

The patient was found to be anuric with grossly deranged electrolytes after the first-stage operation. Tumor lysis syndrome was diagnosed.

INTERVENTIONS

The patient was transferred to the intensive care unit for aggressive fluid administration and continuous venovenous hemofiltration for the management of tumor lysis syndrome.

OUTCOMES

The patient recovered and then underwent the second-stage operation of ALPPS with extended right hepatectomy 8 days after the initial operation without any long-term sequelae.

LESSONS

ALPPS is a relatively new technique in liver surgery, entailing an increased risk of tumor lysis syndrome due to an in situ tumor after the first-stage operation. Clinicians should have a high index of suspicion regarding this potentially lethal complication with prompt management.

Current Surgical Management Strategies for Colorectal Cancer Liver Metastases

Simple Summary

Colorectal cancer is one of the most common cancer diagnoses in the world. At least half of patients diagnosed with colorectal cancer will develop metastatic disease, with most being identified in the liver. Surgical resection of colorectal liver metastases (CRLM) is potentially curative. Surgical resection of CRLM, however, remains underutilized despite the continued expansion of operative strategies available. This is likely due to differing views on resectability. Resectability is a surgical assessment, and the classification of CRLM as unresectable should only be made by an experienced hepatobiliary surgeon. Obtaining a surgical evaluation at the time of liver metastasis discovery may help mitigate the challenge of assessing resectability and the determination of potential operative time windows within current multimodal management strategies. The aim of this review is to help facilitate discussions surrounding resectability as well as the timing and sequencing of both surgical and non-surgical therapies.

Abstract

Colorectal cancer is the third most common cancer diagnosis in the world, and the second most common cause of cancer-related deaths. Despite significant progress in management strategies for colorectal cancer over the last several decades, metastatic disease remains difficult to treat and is often considered incurable. However, for patients with colorectal liver metastases (CRLM), surgical resection offers the best opportunity for survival, can be curative, and remains the gold standard. Unfortunately, surgical treatment options are underutilized. Misperceptions regarding resectable and unresectable CRLM likely play a role in this. The assessment of factors that impact resectability status like medical fitness, technical considerations, and disease biology can be difficult, necessitating careful multidisciplinary input and discussion. The identification of ideal operative time windows that align with the multimodal management of these patients can also be perplexing. For all patients with CRLM it may therefore be advantageous to obtain surgical evaluation at the time of discovering liver metastases to mitigate these challenges and minimize the risk of undertreatment. In this review we summarize current surgical management strategies for CRLM and discuss factors to be considered when determining resectability.

Case Report: Robotic ALPPS Procedure for Hepatocellular Carcinoma in the Right Lobe of the Liver

Introduction: Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) is a surgical procedure for liver malignancy where the volume of the liver remnant is estimated to be too small. We present the first case of two-stage robotic ALPPS procedure, illustrating the steps and advantages of robotic surgery. Materials and Methods: A 68-year-old man with morbid obesity (BMI 40), portal fibrosis, macrovesicular steatosis, and poor liver function underwent robotic ALPPS for hepatocellular carcinoma in the right lobe of the liver (segments 5, 7, and 8). A video presentation (https://youtu.be/M50Gumf-4pw) of the operative procedure is accompanied by explanation in the text with embedded corresponding video time points. Results: Both stages of the procedure were performed robotically, with negligible blood loss, and rapid surgical recovery. The patient died 3 years later. Discussion: Robotic ALPPS offers reduced morbidity in major liver surgery for malignancy and may extend survival in meticulously selected patients.

Successful treatment of a huge hepatic carcinoma with right portal vein thrombosis: A case report

INTRODUCTION

Unlike the traditional associating liver partition and portal vein ligation for staged hepatectomy, it is still controversial whether patients with portal vein thrombosis can receive benefits from liver partition.

PATIENT CONCERNS

Right upper abdominal distension for 2 months.

DIAGNOSIS

Hepatocellular carcinoma with portal vein invasion INTERVENTION:: Radiofrequency-assisted liver partition with portal vein ligation (RALPP) OUTCOMES:: Disease-free survival: 3 months, overall survival: 7 months CONCLUSION:: Our results advocate this variation of RALPP for use in patients with huge HCC with portal vein invasion, without enough future liver remnant. Patients can receive benefits from the operation, including a shorter operation time, better recovery, and lower overall costs of the 2-stage procedure.

A preliminary study of associating liver partition and portal vein ligation for staged hepatectomy in a rat model of liver cirrhosis

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in a rat model of liver cirrhosis has not, to the best of our knowledge, been previously investigated. The present study therefore aimed to establish a model of ALPPS in cirrhotic rats and to assess liver regeneration. Rats were randomly divided into an ALPPS group with carbon tetrachloride-induced cirrhosis (group A) and a normal liver (group B). Rat weight, cytokine levels, biochemical parameters and histopathology were assessed 1, 2, 3, 7 and 14 days after ALPPS. Higher aspartate aminotransferase and alanine aminotransferase levels were detected in group A on the first postoperative day. On the first, second and third days, hepatocyte proliferation rate was higher in group B than in group A. After 3 days, hepatocyte proliferation rate in group B began to decrease, but the rate in group A continued to increase until the 14th day. Higher levels of hepatocyte growth factor, interleukin-6 and tumor necrosis factor-α were detected in group A compared with group B, but the differences were not significant. The present study demonstrated that ALPPS promoted liver regeneration in a rat model of cirrhosis, but significantly impaired liver function. Compared with the ALPPS model, group B exhibited a delayed peak of proliferation. The mechanism of liver regeneration induced by ALPPS in cirrhotic rats may be associated with increased cytokine levels.

Dealing with insufficient liver remnant: Associating liver partition and portal vein ligation for staged hepatectomy

Liver resection for colorectal liver metastases has emerged to highly successful treatment in the last decades. Key to this success is complete hepatic tumor removal and systemic disease control by chemotherapy. Associating liver partition and portal vein ligation for staged hepatectomy is the most recent two-stage resection strategy for patients with very small future liver remnant making complete tumor removal possible within 1 to 2 weeks. Oncological outcome data are being collected at the moment and first results from small series reveal promising results.

Treatment of primary hepatic neuroendocrine tumors with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): A case report and literature review

RATIONALE

Primary hepatic neuroendocrine tumors (PHNETs) are extremely rare and are difficult to diagnose preoperatively.We report a case of PHNET diagnosed preoperatively and successfully resected using associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).

PATIENT CONCERNS

A 72-year-old woman was admitted to our hospital for a hepatic mass, which was incidentally identified during a routine health checkup. The patient has no other obvious symptoms of discomfort.

DIAGNOSES

Physical examination revealed a palpable mass in the right upper quadrant of her abdomen. Dynamic contrast-enhanced abdominal computed tomography (CT) showed a low-density mass measuring 13 × 7 × 6 cm in both, the right and left hepatic lobes. F-fluorodesoxyglucose positron emission tomography (F-FDG PET) and fused PET/CT showed increased uptake by the mass, which was indicative of a hepatic tumor.

INTERVENTIONS

We use a novel ALPPS surgical procedure to safely and radically remove primary neuroendocrine tumors.

OUTCOMES

No postoperative bleeding and bile leakage were reported, and the patient recovered uneventfully.The patient was followed-up for a year without recurrence.

LESSONS

PHNETs are rare tumors, and confirming the diagnosis using the best possible preoperative examination is important. An optimal treatment plan is selected based on the patient's condition to ensure a favorable prognosis. Tumors too large to undergo surgical removal can be resected using the ALPPS procedure, as described in this case report.

Associating liver partition and portal vein ligation versus 2-stage hepatectomy: A meta-analysis

BACKGROUND

The aim of this study was to conduct a meta-analysis comparing associating liver partition and portal vein ligation (ALPPS) with conventional 2-stage hepatectomy (TSH) in terms of clinical outcomes and to determine the feasibility and safety of ALPPS.

METHODS

A comprehensive search strategy was adopted to search the PubMed, Embase, Cochrane Library, and China Biology Medicine disc databases for studies comparing ALPPS and TSH. The search was broadened by looking up the reference lists of the retrieved articles. A meta-analysis was performed using the statistical software RevMan (v 5.3; Cochrane Collaboration).

RESULTS

A total of 7 studies involving 561 patients (ALPPS group, 136 patients; TSH group, 425 patients) were included in the present study, all of which were observational studies. Compared with TSH, ALPPS was associated with high completion rates of both stages [odds ratio (OR): 10.68, 95% confidence interval (95% CI): 3.26-34.97, P < .0001]. No significant differences were found in other outcomes such as complications of the first (OR: 4.04, 95% CI: 0.81-20.27, P = .09) and second surgical stage (OR: 1.59, 95% CI: 0.71-3.57, P = .26), liver failure (OR: 0.76, 95% CI: 0.29-1.98, P = .58) and the 90-day mortality rate (OR: 2.20, 95% CI: 1.00-4.84, P = .05).

CONCLUSION

ALPPS is associated with lower noncompletion rate and had similar perioperative outcomes relative to TSH. However, only retrospective observational studies were included in this meta-analysis, which may have limited the strength of the evidence. High-quality, large-scale studies are required to further evaluate the outcomes of ALPPS.

Liver regeneration during the associating liver partition and portal vein ligation for staged hepatectomy procedure in Sus scrofa is positively modulated by stem cells

This present study investigated the impact of the application of stem cells to liver regeneration following the first stage of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). The experiment was conducted on a pig model (n=6, 3 that did not receive application of stem cells, 3 that received application stem cells). Collected samples of liver (day 0 and 9 following surgery) were subjected to complete transcriptome sequencing. In total, 39 differentially expressed genes were found in the group without the application of the stem cells (genes of unwanted processes such as fibrosis and inflammation). In the group that did receive application of stem cells, no significantly differentially expressed genes were found, indicating a properly regenerated liver remnant. The present study therefore demonstrated, to the best of our knowledge for the first time, the positive effect of stem cells application in the liver regeneration process during ALPPS procedure in the pig model.

High incidence of biliary stricture after associating liver partition and portal vein ligation for staged hepatectomy

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two-stage procedure most frequently applied in the setting of an extended right-sided hemi-hepatectomy. Initial reports of high mortality have sparked debate regarding the safety and efficacy of the procedure. We describe a higher incidence of early post-operative bile duct strictures after ALPPS, a complication rarely seen after conventional liver resection.

METHODS

An institutional review was conducted to assess the incidence of post-operative biliary strictures following conventional right-sided or extended right-sided hemi-hepatectomy and ALPPS. Patient demographics and operative data were obtained from the patient database of Karolinska University Hospital.

RESULTS

Between 2010 and 2015, 528 hemi-hepatectomies or extended hemi-hepatectomies were performed, of which 500 were conventional liver resections and 28 were ALPPS. The incidence of post-operative biliary stricture was 10.7% (n = 3) following ALPPS, 1.4% (n = 2) following extended right-sided hepatectomy (P = 0.023; OR = 8.46; 95% CI 1.35-53.2) and 1.1% following formal right-sided hepatectomy (P = 0.004; OR = 11.0; 95% CI 2.11-57.6). All biliary strictures were at the level of the hilum affecting the left hepatic duct. Pre-operative comorbidity was less in the ALPPS group and post-operative complications were more severe following ALPPS.

CONCLUSION

Iatrogenic biliary strictures following conventional liver resection is an uncommon complication. It does, however, occur more frequently following ALPPS and is associated with an increased morbidity. Caution should therefore be exercised when dividing the right hilar pedicle at stage 2 of ALPPS.

Applying negative pressure wound therapy in associating liver partition and portal vein ligation for staged hepatectomy: A case report

Staged hepatectomy, particularly associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a recently developed advanced surgery for resecting liver tumors. However, large wound surfaces, incomplete drainage and high rates of mortality are vital limitations of ALPPS. The present case study describes a patient with liver cancer who underwent ALPPS surgery combined with negative pressure wound therapy. A 46-year-old male patient was hospitalized due to right upper abdominal pain. Computed tomography and magnetic resonance cholangiopancreatography scan results indicated gallbladder cancer, accompanied by multiple liver metastases. Resection of the right trisegment and partial resection of metastatic nodules in the left outer lobe were performed. Vacuum sealing drainage was pre-implanted at liver cross-sections with drainage tubes to drain the bile. The patient exhibited improved wound healing compared with conventional ALPPS.

Safety and efficacy of radiofrequency-assisted ALPPS (RALPPS) in patients with cirrhosis-related hepatocellular carcinoma

BACKGROUND AND AIMS

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has high morbidity and mortality. In this study, the safety and efficacy of a modification of ALPPS (radiofrequency-assisted ALPPS, RALPPS) were assessed in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Patients who were diagnosed with HCC and were considered to have an insufficient future liver remnant (FLR) were enrolled. In stage I, a radiofrequency ablation (RFA) device was used to cauterise along the planned transection plane to form a coagulum avascular area. When the FLR reached above 40%, hepatectomy was performed in stage II along the coagulum area established previously. After two stages, operative morbidity, mortality, per cent increase in FLR, operative time and blood loss were evaluated.

RESULTS

Between July 2014 and September 2015, 10 patients with HCC (9 with hepatitis-related cirrhosis) were treated with the RALPPS procedure. The incidence of severe complications (Clavien-Dindo ≥ IIIb) was 20% (2/10). One patient died. No biliary leakage, intraperitoneal infection or post-hepatectomy liver failure (PHLF) occurred after both stages. The median FLR before stage I was 31% (364 ml). This increased to 47% (632 ml) before stage II after a median interval of 28 days. The median percentage increase in FLR was 53% (210 ml). Additionally, the median operative time during the first and second stages was 214 and 281 min, respectively. The corresponding median blood loss was 200 and 550 ml, respectively.

CONCLUSIONS

RALPPS has a potential advantage in eliminating serious complications of biliary leakage and PHLF associated with classic ALPPS. On the basis of rigorous patient selection criteria, RALPPS may achieve the same effect of promoting significant growth of the FLR in patients with cirrhosis-related HCC and insufficient FLR volume, albeit at the cost of a longer interval time.

Associating Liver Partition and Portal Vein Ligation for Primary Hepatobiliary Malignancies and Non-Colorectal Liver Metastases

Background and Aims:

Associating liver partition and portal vein ligation for staged hepatectomy may increase the possibility of radical resection in the case of liver malignancy. Concerns have been raised about the high morbidity and mortality associated with the procedure, particularly when applied for diagnoses other than colorectal liver metastases. The aim of this study was to analyze the initial experience with associating liver partition and portal vein ligation for staged hepatectomy in cases of non-colorectal liver metastases and primary hepatobiliary malignancies in Scandinavia.

Materials and Methods:

A retrospective analysis of all associating liver partition and portal vein ligation for staged hepatectomy procedures performed at two Swedish university hospitals for non-colorectal liver metastases and primary hepatobiliary malignancies was performed. The primary focus was on the safety of the procedure.

Results and Conclusion:

Ten patients were included: four had hepatocellular cancer, three had intrahepatic cholangiocarcinoma, one had a Klatskin tumor, one had ocular melanoma metastasis, and one had a metastasis from a Wilms’ tumor. All patients completed both operations, and the highest grade of complication (according to the Clavien-Dindo classification) was 3A, which was observed in one patient. No 90-day mortality was observed. Radical resection (R0) was achieved in nine patients, while the resection was R2 in one patient. The low morbidity and mortality observed in this cohort compared with those of earlier reports on associating liver partition and portal vein ligation for staged hepatectomy for diagnoses other than colorectal liver metastases may be related to the selection of patients with limited comorbidity. In addition, procedures other than associating liver partition and portal vein ligation for staged hepatectomy had been avoided in most of the patients. In conclusion, associating liver partition and portal vein ligation for staged hepatectomy can be applied to primary hepatobiliary malignancies and non-colorectal liver metastases with acceptable rates of morbidity and mortality.

Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion -- an extension of the ALPPS approach

BACKGROUND

Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new "ALPPS" approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE.

METHODS

A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed.

RESULTS

The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection.

CONCLUSION

Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.