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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curative intent at our center (unpublished data).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