| Background and Aims: Surgical resection is widely accepted as one of the most important methods in the curative treatment of liver cancer.However,for the patients with advanced HCC,stage B or C in BCLC staging classification,the recommended treatment is palliative care based on TACE.The main limiting factor for these patients undergoing the surgical resection is the insufficient future liver remnant(FLR)volume.In recent years,a novel procedure,the ALPPS(associating liver partition and portal vein ligation for staged hepatectomy),which can significantly promote the growth of FLR in a short period of time,provides an operation opportunity for patients with initially unresectable liver cancers.However,classic ALPPS has high operative morbidity and mortality.We applied RALPPS(radiofrequency ablation-assisted ALPPS,RFA-assisted ALPPS),a modified procedure for classic ALPPS using RFA,in the treatment of patients with advanced cirrhosis-related hepatocellular carcinoma(HCC),analyzing the patients' clinical parameters during perioperative period and evaluating the clinical effect of the procedure.Besides,we also investigated the role of RFA in promoting further regeneration of the liver tissue when the FLR has an insufficient volume after first stage of RALPPS.Methods: RALPPS was performed in HCC patients with insufficient FLR(<40%).In the first stage,an avascular coagulation area was cauterized by a RFA device along the planned transection plane,instead of liver partition in the classic ALPPS,and then the right branch of portal vein was ligated.After the operation,the FLR volume was assessed by computed tomography(CT)every week.When the FLR reached above 40% and the patient was in good condition,hepatectomy was performed.For the patients with FLR below 40% after 2-3 weeks of the first stage,additional percutaneous RFA(named “rescue RFA”)was performed under the guidance of color ultrasound.At last,we evaluated the operative morbidity,mortality,percent increase in the FLR,operative time and blood loss,the completion rate of two stages of RALPPS,the overall survival(OS),disease free survival(DFS),the increase of the FLR before and after the rescue RFA and other parameters.Results:From July 2014 to August 2016,21 HCC patients were treated with RALPPS procedure,of which 15 cases accompanied with cirrhosis.5 patients did not undergo the second stage operation of hepatectomy for different reasons,with the rate of drop-off for the second stage 23.8%.One patient died in hospital,and the in-hospital mortality was 4.8%(1/21);the incidence of severe complications(Clavien-Dindo ??b)was 23.8%(5/21).The FLR volume increased from 372.5±93.4ml(29.0±6.8%)to 372.5±93.4ml(29.0±6.8%)during the interval time of 25.2±14.8 days.The blood loss in the first and second stage was 190.5±115.8 ml,513.1±240.7ml respectively;correspondingly,the operative time was 224.5±58.3 min,309.0±83.8 min,respectively.With a follow-up for a median of 16 months(2-30 months),the OS was 45.7%,and the DFS was 44.4%.There were 4 patients treated with rescue RFA when they had insufficient FLR volume after 2-3 weeks of the first stage.Before the implementation of rescue RFA,the growth rate of FLR was 0.3-7.5%,which increased to 9.7-12.1% after the implementation.Conclusions: RALPPS is a safe,efficient and simple modified surgical procedure in comparison with classic ALPPS;with highly strict patient selection criteria,the FLR could also regenerate well in advanced cirrhosis-related HCC patients with good liver function,although the rate of drop-off for the second stage of RALPPS is a little high.To reduce the rate of drop-off,rescue RFA may provide a potential choice for the patients with insufficient FLR volume after the first stage of RALPPS,albeit the exact effect still needs to be confirmed by large number of sample studies.In addition,for the popularization and application of RALPPS,it is necessary to explore and screen the risk factors of the poor FLR regeneration in cirrhosis-related HCC patients and then to establish a risk prediction model. |
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