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Page 4 of 9 Malerba et al. Hepatoma Res 2021;7:19 I http://dx.doi.org/10.20517/2394-5079.2020.131

Laparoscopic rescue ALPPS completion
The procedure started with a complete mobilization of the right liver, followed by the dissection of the
hepatic pedicle and the division of the right hepatic artery between 3 Hem-O-Lok® clips. At this point,
the parenchyma transection already started during the first operation was completed under intermittent
hepatic pedicle occlusion as described above. The transection line passed between the right and left liver
in the lower hepatic segments but cranially was shifted in the anterior right section, with intraparenchymal
identification and transection of the right hepatic vein. This was due to the preoperative right hepatic vein
(RHV) embolization, with embolizing material extending up to a few centimeters from the RHV-inferior
vena cava (IVC) confluence and with a potentially high risk of dealing with a short and fragile RHV stump
in case of venous transection close to the IVC confluence. Thus, we felt that separating the RHV some
centimeters proximal to the IVC confluence, thus shifting the transection line to the right anterior section,
preserving a longer venous stump, and finally performing a partial right hepatectomy, was a safer and
oncologically acceptable option.

This operation duration was 380 minutes and the estimated blood loss was about 600 mL [Video 1].

The postoperative course was uneventful, and the patient was discharged 5 days after the ALPPS
completion. The histopathological examination revealed a 13-cm moderately differentiated HCC (pT2Nx),
and the nontumoral liver parenchyma assessment revealed fibrosis without signs of cirrhosis. All resection
margins were clear.

DISCUSSION
[15]
HCC represents the most common primary hepatic tumor , and liver resection, after liver transplantation,
[16]
is the most effective treatment for patients with HCC . When a major hepatectomy is planned, the FLR
volume needed to minimize the risk of PHLF should take into account the quality of the FLR parenchyma.
For a patient with a normal liver parenchyma, an FLR volume of at least 20%-25% may be considered
sufficient, but among patients with HCC, due to the frequent coexistence of chronic (in the majority
of cases virus-related or exotoxic) hepatitis, the need for an FLR volume higher than 30%-35% is often
[17]
[18]
required . Multiple strategies to induce an adequate FLR hypertrophy have been described . The case
we report herein of an obese patient with a large right liver HCC, with HBV-related chronic hepatitis and
a small FLR volume, shows how a modular use and a multi-step integration of different liver remodelling
techniques may lead to achieving the required FLR hypertrophy before major liver resection, even in a
particularly challenging case.

PVE, representing the most commonly used procedure to induce FLR hypertrophy, has been reported
[19]
to have a success rate between 75% and 96% and has been associated with low incidence of PHLF and
[20]
mortality (6 and 3.6%, respectively) . This was the first procedure performed in this case per our usual
protocol [21,22] , with a suboptimal increase in future liver volume (from 26 to 34%), but the ICG clearance
test, subsequently performed, revealed a severely impaired liver function.

When PVE was followed with a right HVE, no significant improvement was seen. This is in contrast to the
results from recent studies, suggesting that sequential HVE, achieved thanks to the centrilobular congestion
within the embolized territory immediately following the procedure , may help to increase FLR
[23]
hypertrophy in case of insufficient growth after PVE [19,24] . It should be highlighted that evidence concerning
such strategy is quite limited and refer to small series of patients, suggesting that more studies concerning
this issue are needed to confirm the efficacy of such strategy. In the current case, right HVE was shown to be
safe but achieved only a marginal increase in FLR volume (from 34% to 35%) and a minimal improvement
in liver function. It is possible that a better outcome could have been achieved if the HVE was performed
simultaneously with the PVE as described in an experimental study by Van Lienden et al. .
[25]