Clinical Research Of Laparoscopic Associating Liver Partition And Portal Vein Ligation For Staged Hepatectomy For HCC With Liver Cirrhosis

BackgroundIn China 80% of HCC combined with liver cirrhosis.For HCC with liver cirrhosis,FLV should be more than 40% of SLV after liver resection.More than 70% of HCC is large HCC when first discovery.Due to insufficient of FLV,many HCC lost opportunity of radical resection,whose survival time is only half a year.The insufficient of FLV is the most important factor to limit major liver resection.Such as PVE,traditional treatments for stimulating the liver hyperplasia need 4-6 weeks or more.FLV increase by only 20%-35%.Some patients cannot go to stage two for insufficient hyperplasia or tumor progression.Associating liver partition and portal vein ligation for staged hepatectomy is a new approach for patient which tumor is previously considered unresectable during one hospital stay.It is considered to be a revolutionary operation strategy or a milestone of hepatobiliary surgery.By the end of 2015,Global ALPPS website registered 568 cases,mainly researching for open ALPPS treatment of metastatic liver cancer.ALPPS is innovation operation,surgeons are constantly trying to improve surgical technique to decrease surgical risk.There are mainly two aspects: one,both stages are traditional laparotomy surgery,patients need to experience two complex liver surgery in the short term,leading to higher mortality and complication.The other one,ALPPS reported in literatures,mainly research on metastatic liver cancer without cirrhosis.Liver resection is difficult for liver cirrhosis,which even in open surgery is more technical challenge than liver without cirrhosis.Laparoscopic liver resection for liver cirrhosis is reserved for major center and experienced experts.The reported research has indicated that adhesion after laparoscopic surgery is lighter,that is good for laparoscopic surgery again.Based our mature technology of laparoscopic liver resection and experience of more than 700 cases of liver resection for liver cancer with cirrhosis(including reoperation for liver resection),we believe that L-ALPPS for HCC with liver cirrhosis is safe and feasible,which could achieve radical resection for advanced liver cancer,with advantage of minimally invasive.L-ALPPS for HCC with liver cirrhosis is an innovative,difficult and high technical required approach,which hasn't been reported.There is not clear whether rapid hyperplasia of the cirrhotic liver in the short term could satisfies the requirement of major liver resection.Based on the status quo,this study attempted to establish the technical methods of L-ALPPS,and explore the safety,feasibility,effectiveness and potential advantages of L-ALPPS for HCC with liver cirrhosis.MethodsA total of 31 patients including 11 patients underwent L-ALPPS(L-ALPPS group)and 20 patients received conventional non-surgical treatment(CG group)for HCC with liver cirrhosis between October 1,2013,and March 31,2016,were included in the study.General information,hyperplasia of future liver,operative interval and perioperative course were analysis prospectively with literatures(totally 9 literatures,n>10)reported in the same period.And the oncologic outcomes were compared with the CG group.Results31 patients were recruited including 24 mail and 7 female,average age 47(range 35-65).There was no significant difference between the L-ALPPS group and the CG group in general information.All 11 cases in L-ALPPS group completed laparoscopic surgery in 1st stage,one of which lost the opportunity to 2ndstage two for insufficient FLV and extra hepatic metastases.The other 10 cases were completed L-ALPPS.R0 resection rate was 100%.Operative interval was 14(11-34)day.Five patients were completed totally L-ALPPS,two patients required conversion to laparotomy.Due to space-occupying effect formed by the future liver and spleen and space limit in abdominal cavity,the other five patients were completed laparoscopic surgery in 1st stage and laparotomy in 2ndstage.Surgical approaches included 5 right hemihepatectomy,3 expansion of right hemihepatectomy,1 right trisectiontomy,and 1 right trisectiontomy with caudate lobectomy.The operative time was 257.2±31.7min in 1st stage and 251.5±117min in 2ndstage,transfusion rate was 9.1% in both stage,and postoperative hospital stay was 12.6±8.7d.Proliferative rate of FLV was 42(18-133)%,the median time of hyperplasia was 10(7-36)days,the average KGR was 15.6±11.7cc/d.Ten postoperative complications occurred in six patients(54.5%),including 2(18.2%)complications occurred after 1st stage and other 8(36.3%)after 2ndstage.No postoperative complications were observed in 5 patients.Except 1(9.1%)patient suffered sudden cardiac death after 2ndstage,no serious complications occurred in all of the other patients.20 patients were recruit in CG group including 7 patients underwent TACE,5 patients underwent TACE+ sorafenib and 8 patients underwent other treatments.During overall follow-up time 8.9 months(range 3–28 months),5 cases in L-ALPPS group recurred,one of which died,and the rest survived with tumor;12 cases in cp group recurred,ten of which died,two patients survived with tumor.Oncology results in L-ALPPS group is better than that of CG group in 6-month,1-year rates of overall survival were(100% vs 55%;P<0.05),(90% vs 55%;P=0.06).A totally nine reports(number of cases range 11-48)describing ALPPS were retrieved,operative time was 252-453 min,intraoperative blood loss was 496-725 ml,transfusion rate was 9%-33.3% in 1st stage,operative time was 59-225 min,intraoperative blood loss was 100-270 ml,transfusion rate was 9.2%-43.3% in 2nd stage.Proliferative rate of FLV was 54-93%,the median time of hyperplasia was 6-14 days,R0 resection rate was 71%-93.1%.Rate of postoperative complications was 36%-92% and postoperative hospital stay was 16-19 days.Compared with literature,perioperative results of L-ALPPS group was superior to traditional ALPPS,and the speed of future liver hyperplasia a little slower.ConclusionWe completed 11 cases of L-ALPPS,preliminary established and firstly reported L-ALPPS technology and methods for HCC with liver cirrhosis.This study found that liver with cirrhosis still has the ability to proliferate in a short time,but the speed of future liver hyperplasia a little slower than the hyperplasia of time more than slightly extended cirrhosis of the liver without cirrhosisCompared with literature and CP group,oncology results in L-ALPPS group is better than that of CG group and perioperative results of L-ALPPS group was superior to traditional ALPPSThis study preliminarily confirmed L-ALPPS for HCC with liver cirrhosis was safe and feasible.Owing to the limitations of this study,large-scale prospective multicenter randomized controlled studies are warranted to gather further evidence.