Single center experience with ALPPS and timing with stage 2 in patients with fibrotic/cirrhotic liver

Abstract

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel procedure for major resection in patients with insufficient future liver remnant (FLR). Effective FLR augmentation is pivotal in the completion of ALPPS. Liver fibrosis/cirrhosis associated with chronic viral hepatitis impairs liver regeneration. To investigate the augmentation of FLR in associating ALPPS between patients with fibrotic/cirrhotic livers (FL) and non-fibrotic livers (NFL) and compare their short-term clinical outcomes and long-term survival. Patients were divided into two groups based on the Ishak modified staging: non-fibrotic liver group (NFL, stage 0) and fibrotic/cirrhotic liver group (FL, stage 1-5/6). Weekly liver regeneration in FLR, perioperative data, and survival outcomes were investigated. Twenty-seven patients with liver tumors underwent ALPPS (NFL, n = 7; FL, n = 20). NFL and FL patients had viral hepatitis (28.6% [n = 2] and 95% [n = 19]), absolute FLR volume increments of 134.90 ml and 161.85 ml (p = 0.825), and rates of hypertrophy were 16.46 ml/day and 13.66 ml/day (p = 0.507), respectively. In the FL group, baseline FLR volume was 360.13 ml, postoperatively it increased to a plateau (542.30 ml) in week 2 and declined (378.45 ml) in week 3. One patient (3.7%) with cirrhotic liver (stage 6) failed to proceed to ALPPS-II. The overall ALPPS-related major complication rate was 7.4%. ALPPS is feasible for fibrotic liver patients classified by Ishak modified stages ≤ 5. After ALPPS-I, 14 days for FLR augmentation seems an appropriate waiting time to reach a maximum FLR volume in these patients.

Keywords: ALPPS; Hepatocellular carcinoma; Liver fibrosis/cirrhosis; Liver regeneration; Remnant liver volume; Viral hepatitis.

Fig. 1

A Future liver remnant volume increased rapidly in the first week after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS-I) and slowed to a plateau in postoperative week 2 in the non-fibrotic liver group. In fibrotic liver group, liver regeneration continued and peaked in postoperative week 2 and the hypertrophic liver began to shrink during postoperative week 3. B Increments in FLR/SLV per day reached the highest level in postoperative week 1 then declined. Hypertrophic livers began to shrink during postoperative week 3. Increments in FLR/SLV per day in weeks 1 and 2 were 1.43% and 0.43% (p = 0.105), respectively in the non-fibrotic liver group and 1.47% and 0.42% (p < 0.001), respectively in the fibrotic liver group. FLR future liver remnant, SLV standard liver volume, W0 pre-ALPPS surgery, W1 week 1 after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS-I) operation, W2 week 2 after ALPPS-I operation, W3 week 3 after ALPPS-I operation

Fig. 2

Postoperative course of biochemical blood tests following ALPPS-I and ALPPS-II: A AST. B ALT, aminotransferase levels (AST, ALT) following ALPPS-I peaked on POD 1, and then decreased. After ALPPS-II, aminotransferase levels did not show fluctuation. C INR following ALPPS-I peaked on POD 1 and returned to normal values on POD 3 in both groups (C). After ALPPS-II, INR peaked on POD 3 in the NFL group and on POD 5 in the FL group. D Total bilirubin peaked on POD 3 in the NFL group and on POD 5 in the FL group, returning to baseline levels (pre-ALPPS-I) on POD 5 in the NFL group and on the day of ALPPS-II in the FL group (p = 0.065) after ALPPS-I. Transient impaired liver functions during the first week following ALPPS-II may be attributed to the loss of deportalized livers. AST aspartate aminotransferase, ALT alanine aminotransferase, ALPPS associating liver partition and portal vein ligation for staged hepatectomy, POD postoperative day, INR international normalized ratio; stage 1, the day before ALPPS-I; stage 2, the day of ALPPS-II; FL fibrotic liver, NFL non-fibrotic liver

Fig. 3

Overall survival of patients with hepatocellular carcinoma after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)

Fig. 4

Absolute increment in FLR volume/FLV0 (%) after ALPPS. The FLR hypertrophy rate did not show a significant correlation with the severity of liver fibrosis and cirrhosis (p = 0.868). There seems a trend that fibrosis more than moderate stage (2/3) had a negative impact on the hypertrophy of the FLR. ALPPS associating liver partition and portal vein ligation for staged hepatectomy, FLR future liver remnant, FLV0 baseline future liver remnant volume