Abstract
BackgroundThe future liver remnant (FLR) faces a risk of poor growth in patients with cirrhosis-related hepatocellular carcinoma (HCC) after stage-1 radiofrequency-assisted ALPPS (RALPPS). The present study presents a strategy to trigger further FLR growth using supplementary radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI).MethodsAt RALPPS stage-1 the portal vein branch was ligated, followed by intraoperative RFA creating a coagulated avascular area between the FLR and the deportalized lobes. During the interstage period, patients not achieving sufficient liver size (≥ 40%) within 2–3 weeks underwent additional percutaneous RFA/PEI of the deportalized lobes (rescue RFA/PEI) in an attempt to further stimulate FLR growth.ResultsSeven patients underwent rescue RFA/PEI after RALPPS stage-1. In total five RFAs and eight PEIs were applied in these patients. The kinetic growth rate (KGR) was highest the first week after RALPPS stage-1 (10%, range − 1% to 15%), and then dropped to 1.5% (0–9%) in the second week (p < 0.05). With rescue RFA/PEI applied, KGR increased significantly to 4% (2–5%) compared with that before the rescue procedures (p < 0.05). Five patients proceeded to RALPPS stage-2. Two patients failed: In one patient the FLR remained at a constant level even after four rescue PEIs. The other patient developed metastasis. Except one patient died after RALPPS stage-2, no severe complications (Clavien-Dindo ≥ IIIb) occurred among remaining six patients.ConclusionsRescue RFA/PEI may provide an alternative to trigger further growth of the FLR in patients with cirrhosis-related HCC showing insufficient FLR after RALPPS stage-1.Trial registration Retrospectively registered.
Highlights
Portal vein embolization (PVE) or ligation (PVL) is a standard procedure to stimulate liver growth in patients planned for extended hepatectomy but with insufficient future liver remnant (FLR)
In 2012, a novel twostaged hepatectomy strategy where in stage-1 PVL was combined with a liver parenchyma transection between the FLR and the deportalized lobes, followed by hepatectomy in stage-2 emerged as a promising technique for patients with insufficient FLR [2]
radiofrequency-assisted ALPPS (RALPPS) was performed in patients clinically diagnosed with hepatocellular carcinoma (HCC) according to the criteria published by the American Association for the Study of Liver Disease [14], insufficient FLR volume (FLR < 40% in fibrosis/cirrhosis cases), Child–Pugh scoring A, an indocyanine green retention rate at 15 min (ICG-R15) less than 10%
Summary
Portal vein embolization (PVE) or ligation (PVL) is a standard procedure to stimulate liver growth in patients planned for extended hepatectomy but with insufficient future liver remnant (FLR). Compared with solely performing PVE or PVL, the additional liver parenchyma transection in ALPPS produces a dramatic effect: it can generate rapid FLR growth (40–160%) in a short time (6–9 days) [4], allowing a higher completion rate of liver tumor resection (95–100%) [5]. In cases of failed growth after standard PVE, supplementary liver parenchyma transection can still trigger FLR growth, increasing the resectability rate of liver tumors (so-called rescue ALPPS) [6, 7]. The future liver remnant (FLR) faces a risk of poor growth in patients with cirrhosis-related hepatocellular carcinoma (HCC) after stage-1 radiofrequency-assisted ALPPS (RALPPS). The present study presents a strategy to trigger further FLR growth using supplementary radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI)
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