Alpps for the treatment of giant hepatocellular carcinoma

Abstract

Background: Liver resections are the treatment of choice for most liver tumors. Thanks to hepatic regeneration, various procedures have been emerging to stimulate liver hypertrophy in cases where it is required. Among them is the ALPPS (Associative Liver Partition and Portal Vein Ligation for Staged Hepatectomy). Which consists of performing a hepatectomy in two stages, achieving faster hypertrophies and in less time. This surgical technique can have high rates of morbidity and mortality, which is why it is very important to select patients appropriately. Methods: We present our first case of a two-stage hepatectomy using the ALPPS. Male patient of 65 years, with abdominal ultrasound finding of a mass in right hepatic lobe. Magnetic resonance imaging of the abdomen shows a hepatic giant tumor in the right lobe and part of the IV segment compatible with probable hepatocellular carcinoma in a non-cirrhotic liver. Hepatic volumetry and previous preanesthetic assessment were performed with liver, cardiac and pulmonary function tests. Given the insufficient hepatic remnant, and the large tumor burden that it represented, it was decided to perform an ALPPS in order to obtain a more rapid liver hypertrophy. Results: The first stage was performed by laparoscopic technique, achieving right portal ligation (the anterior and posterior branches separately) and the hepatic transection without the need for Pringle's maneuver. The postoperative evolution was without complications. After 10 days, a new abdominal tomography was performed to assess the hypertrophy. A hepatic remnant of almost 40% is achieved. We proceed then to the second stage of the ALPPS, this time with an open approach. The hepatic transection is completed with ligature of the right hepatic artery, control of the right bile duct and section of the hepatic veinhe procedure was without complications, did not require blood transfusion or vasopressor support, extubation was achieved and transfer to ICU for surveillance where it was 2 days. He had no signs of liver failure, and was discharged at 8 days. The pathology reveals hepatocelluar carcinoma on a non-cirrhotic liver. Conclusion: ALPPS is an alternative in the treatment of liver tumors where the liver remnant is insufficient, and because of its tumor biology a hypertrophy is required in less time or when the other forms of hypertrophy have failed. However, it is a procedure that can have high morbidty and mortality, which is why it is important to select patients in a multidisciplinary team.