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Chok Surgical strategy for huge/advanced HCC

a significant survival benefit over TACE in treating METHODS TO INCREASE FLR
HKLC-2 HCC, with a 5-year survival of 49% vs. 0%
(P < 0.001); on the other hand, TACE had a significant In order to increase the chance and safety of major
survival benefit over systemic therapy in treating hepatectomy for HCC patients, preoperative portal
HKLC-3 HCC, with a 3-year survival of 10% vs. 2% vein embolization has been used to increase FLR.
(P < 0.001). If the patients are young, fit and properly The idea of portal vein embolization is to embolize
selected, aggressive resection may still be beneficial (in an open or percutaneous manner) the portal vein
despite large or multiple nodules or intrahepatic ipsilateral to the liver lobe harboring the tumor, so as to
venous invasion. [8] induce hypertrophy of the FLR. [28,29] However, it usually
takes at least four weeks for the FLR to hypertrophy
Disease treatment should be individualized. In general, enough. [29] During the time, disease progression may
surgical resection is the core curative treatment for huge occur. If there is tumor invasion of a major vessel (e.g.
and advanced HCC in Hong Kong. the ipsilateral portal vein), the disease can progress
in terms of weeks. If contralateral propagation and
HCCS OF 10 CM OR BIGGER metastasis develop, the tumor will be inoperable. [30-32]
And sometimes hypertrophy does not occur as
Hepatectomy is the first-line HCC treatment for tumor anticipated.
clearance and a cure for patients with preserved liver
function. [3,9,10] For HCCs ≥ 10 cm, major hepatectomy Associating liver partition and portal vein ligation
is usually needed. Measures to ensure safe major for staged hepatectomy (ALPPS) is a relatively new
hepatectomy with acceptable complication and method of increasing FLR and is gaining popularity.
perioperative mortality rates include careful patient It features two open operations. In the first operation,
selection (patients should be fit for surgery and with liver partition and portal vein ligation are performed
preserved liver function), [9,11] adoption of the anterior to induce hypertrophy of the FLR while no resection is
approach to avoid mobilization and rupture of large done. When the FLR has hypertrophied enough, the
tumors, [12] close liaison with the anaesthesiologist to second operation is conducted for tumor resection.
ensure a low central venous pressure in order to reduce ALPPS is particularly useful if there is ipsilateral
blood loss, [13] and use of surgical instruments (such as portal vein tumor thrombosis (PVTT) because the
Cavitron Ultrasonic Surgical Aspirator). [9,14-16] Major first operation also prevents further propagation of
hepatectomy may not be possible for patients who the thrombus into the main and contralateral portal
have marginal liver function or a relatively small future veins. ALPPS was initially applied to relatively
liver remnant (FLR). At our center, we use Indocynaine normal liver, such as that in the case of colorectal
green (ICG) clearance test to assess preoperative liver liver metastasis. [33-36] Subsequently its application
function. [17] For consideration for major hepatectomy, an was extended to steatotic liver and cirrhotic liver. [37-39]
ICG retention rate ≤ 14% at 15 min is required. Besides With ALPPS, the increase of FLR between the two
ICG test result, other factors are also taken into account. operations can be as high as 70%, [40] and it usually takes
A low platelet count, poor renal function test results and only one week to achieve enough hypertrophy. ALPPS
the presence of significant morbidity can mean a risky outperforms conventional portal vein embolization
major hepatectomy. An adequate FLR with preservation when it comes to time and extent of hypertrophy. [41,42]
or reconstruction of major hepatic veins and meticulous As the interval between the two operations is not long,
surgical skills to avoid massive bleeding and vascular adhesion formation resulting from the first operation is
insult to the liver are essential to a successful major relatively immature when the second operation takes
hepatectomy. [18] FLR is assessed by calculation of the place, thereby allowing continuation of dissection and
liver volume measured by tracing the liver contour on resection of the liver with ease.
the cross sectional image on computed tomographic
volumetry, and the University of Hong Kong formula is However, there is no guarantee that adequate
used at our center. [19,20] A patient’s estimated standard hypertrophy always occur, and liver failure might result
liver volume (ESLV) can be derived from the patient’s from the portal vein ligation. The Pringle maneuver is
weight, height, and body surface area. [20,21] Patients not advisable as it poses further risk of liver injury. Our
with liver cirrhosis and relatively poor liver function center has simplified the ALPPS procedure by using
need a bigger FLR. [22-25] At our center, we use a ratio of an anterior approach to allow liver transection without
FLR/ESLV of > 35% for major hepatectomy for patients mobilization of the right lobe, and as such the amount
who have Child-Pugh A cirrhosis and an ICG retention of adhesion is decreased, thereby streamlining the
rate ≤ 14% at 15 min. [26] Liver cirrhosis and inadequate second operation. [39] The hilar plate and the right
FLR are risk factors for postoperative liver failure. [25,27] hepatic duct are left untouched in the first operation

190 Hepatoma Research ¦ Volume 3 ¦ September 03, 2017