ALPPS for Hepatocarcinoma under Cirrhosis: A Feasible Alternative to Portal Vein Embolization

Abstract

Introduction: Advancements in laparoscopic liver resection (LLR) has revolutionized the field of liver surgery. Currently, indocyanine green (ICG) fluorescent image technology is developed as intraoperative navigation tool to detect tumors and demarcation line in LLR. We assessed significance and surgical outcomes of ICG fluorescent surgery in LLR for navigation of demarcation line and intersegmental plane. Methods: We assessed 118 cases who had been performed LLR in our hospital. ICG fluorescent imaging was used with VECELA ELITE IIÒ (Olympus) or PINPOINTÒ (Stryker). Preoperative 3D simulation was performed and evaluated glissonian pedicle feeding the tumor. After clamping glissonian pedicle, we injected 2.5 mg of ICG intravenously. Then, demarcation line was assessed to decide transection line. During parenchymal transection, visualization of intersegmental plane was also assessed. In eight cases (S6: 3patients, S5: 1patient, S3: 4patients), we performed this technique and assessed intraoperative navigation of transection line and surgical outcomes. Results: In all cases, demarcation line could be detected by ICG navigation. New system of ICG fluorescent navigation could be detected intersegmental plane during parenchymal transection. In this series, surgical outcome was acceptable compared with other cases, and had no major complication and no mortality. However, it was difficult to recognize bleeding points from hepatic veins in ICG fluorescent mode of camera. To assure bleeding points, it is still needed to use normallight mode of laparoscopy system. Conclusion:The new system of ICG fluorescent navigation makes it possible to visualize not only superficial demarcation line but intersegmental plane during parenchymal transection in LLR.

Liver resection in Cirrhotic liver: Are there any limits?

“…Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) [51] is gaining momentum as an alternative for liver augmentation for the higher degree and more rapid enlargement of FLR than PVE. The high short-term morbidity and mortality rates reported in the early series have considerably improved over the years due to the establishment of the international ALPPS registry (http:// www.alpps.net/?q=registry) and technical refinements [52]. However, D'Hasse et al reported an unacceptably high 90-day mortality of 31% in patients who underwent ALLPS for HCC (n = 35), which was almost fivefold higher than that for colorectal liver metastases (n = 225; 90day mortality, 7%, p < 0.001) based on the aforementioned registry data.…”

Oncological benefits of portal vein embolization for patients with hepatocellular carcinoma

“…The first step includes tumor enucleation of the FLR followed by PVE or PVL, while the second step involves major hepatectomy. [70][71][72] Associated liver partition and PVL for staged hepatectomy (ALPPS) is a novel operative procedure consisting of two steps:…”

“…(a) PVE or PVL and liver transection with or without tumor enucleation from the residual liver, and (b) major hepatectomy. [70][71][72] ALPPS technique has been described to obtain an increased volume of PVE and a decrease in dropout rates. [70][71][72] ALPPS could be a feasible technique only in selected patients with HCC and cirrhosis.…”

“…[70][71][72] ALPPS technique has been described to obtain an increased volume of PVE and a decrease in dropout rates. [70][71][72] ALPPS could be a feasible technique only in selected patients with HCC and cirrhosis. 71,72 The 3-and 5-year DFS and OS rates were 34.9%, and 25.0%, and 41.8%, and 40.7%, respectively (P = .267), and 60.2% and 46.8%, and 73.5%, and 64.1%, respectively (P = .234), in the ALPPS and PVE groups.…”

“…[70][71][72] ALPPS could be a feasible technique only in selected patients with HCC and cirrhosis. 71,72 The 3-and 5-year DFS and OS rates were 34.9%, and 25.0%, and 41.8%, and 40.7%, respectively (P = .267), and 60.2% and 46.8%, and 73.5%, and 64.1%, respectively (P = .234), in the ALPPS and PVE groups. Recently, several types of modified ALPPS procedure including laparoscopic partial ALPPS have been developed mainly to decrease morbidity and mortality.…”