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Chok                                                                                                                                                                           Surgical strategy for huge/advanced HCC

           to minimize the chance of bile leakage, a complication   bifurcation, treated by en bloc resection with portal vein
           that might lead to biloma, infection and sepsis and thus   reconstruction; group 3 (n = 7), with PVTT extending to
           prohibit the second operation. ALPPS is a technically   or beyond the bifurcation, treated by thrombectomy. [48]
           demanding and challenging procedure that should not   The median survival duration was 10.9 months in group
           be performed by inexperienced surgeons.            1, 9.4 months in group 2, and 8.6 months in group 3. No
                                                              significant differences were found in terms of hospital
           ALPPS should be offered with curative intent when a   mortality and morbidity between en bloc resection
           large tumor load is encountered and a marginal FLR is   and thrombectomy. The practice of living donor liver
           anticipated. [41]  Major vascular invasion, such as portal   transplantation at our center certainly had contributed
           vein involvement, does not preclude its application. [35]   to the low morbidity after portal vein resection. [49]  The
           Many patients who would otherwise be unsuitable for   1-, 3- and 5-year survival rates were 50%, 13% and
           major  hepatectomy  are  rendered  eligible  by  ALPPS;   13% respectively in group 2, and 29%, 14% and 14%
           the operation rate is thus raised. Nonetheless, the   respectively  in  group 3.  The  two approaches  again
           procedure entails higher rates of surgical complication   showed no significant differences in terms of overall
           and mortality when compared with conventional      survival and disease-free survival,  and patients with
           major hepatectomy. The reported perioperative      ipsilateral PVTT also had similar survival to patients
           mortality rates range from 12% to 28% [40,41,43,44]  and   with PVTT  extending to or beyond the bifurcation.
           the complication rate can be as high as 50%. [43,45]    These survival outcomes are superior when compared
           Liver insufficiency (e.g. ascites, persisting cholestasis,   with a median of 2.7 months of survival of patients with
           sepsis), bile leakage, septic complications and failure to   PVTT not treated.
                                                                              [1]
           proceed to the second operation have been reported.
           The long-term outcomes of ALPPS are still pending.   Patients with advanced PVTT may not be suitable for
           Since 2014, 21 patients have undergone ALPPS with   resection due to underlying medical conditions and main
           curative intent at our center (unpublished data). All of   portal vein involvement, and non-surgical treatment is
           them had R0 resection. No hospital mortality occurred.   their chance. The combination therapy using sorafenib
           Three (14%) patients developed major complications.   and  TACE  appears  to  provide  a  survival  benefit  for
           The overall survival was 89% and the disease-free   patients with PVTT and adequate liver function. This
           survival was 58% at one year. With time goes by, more   benefit seems to be more pronounced in patients whose
           data will be available.                            first-order  or  more  distal  branches  of  the  portal  vein
                                                              are involved [50]  than in patients with main portal vein
           INVASION OF THE MAJOR PORTAL VEIN,                 involvement. [51]   Head-to-head  comparison  between
           HEPATIC VEINS, OR THE INFERIOR VENA                surgical and non-surgical treatments is warranted.
           CAVA
                                                              One point  to note is  that  patients  may  have falsely
           In the case of  ipsilateral PVTT,  the  thrombus  is   elevated preoperative ICG retention rates due to PVTT.
           confined  to  the  liver  lobe  harboring  the  HCC  and  is   Exploration should be offered to patients who fail their
           usually resected when hepatectomy is conducted     ICG test but otherwise show normal liver function.
           to remove the HCC. For the management of PVTT      With accumulation of expericence from living donor
           extending to the portal vein bifurcation or farther to the   liver transplantation, resection of major vessels such
           main or contralateral portal vein, different approaches   as portal and hepatic veins should yield satisfactory
           have been advocated. It is believed that  en bloc   results.
           resection (resection of tumor together with all affected
           parts of the portal vein) can achieve good oncological   If the tumor thrombus in the inferior vena cava (IVC)
           outcomes with residual microscopic foci removed.   or hepatic vein is non-adhering,  thrombectomy
           Nonetheless,  this  is  a challenging approach since   should  suffice  [Figure 1]. Sometimes IVC resection
           subsequent  portal  vein  reconstruction  is  required.   with immediate reconstruction should be considered,
           On the other hand, it has been documented that     especially for young patients. Some technical issues
           thrombectomy can yield similar survival outcomes with   need to be considered when IVC resection with
           lower operative mortality and morbidity. [46-48]   immediate  reconstruction  is  required.  First,  if  the
                                                              lesion  is  above  the  hepatic  vein  confluence,  total
           In a previous study trying to address the controversy   vascular exclusion with the Pringle maneuver and
           about  en  bloc  resection  versus  thrombectomy,  we   re-implantation of  the hepatic  veins  are necessary.
           compared 3 groups of patients: group 1 (n = 71), with   Second, it is the lesion’s relation to the lower level of
           ipsilateral  PVTT  resected  in  a  hepatectomy;  group   the IVC resection (i.e. the renal vein level). In fact, the
           2  (n  =  10),  with  PVTT  extending  to  or  beyond  the   chance of renal vein invasion is very low. If there is

                           Hepatoma Research ¦ Volume 3 ¦ September 03, 2017                              191
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