Safety and efficacy of radiofrequency-assisted ALPPS (RALPPS) in patients with cirrhosis-related hepatocellular carcinoma

Figures & data

Figure 1. A RFA device was used to cauterise along the future transection plane. A 2-cm-wide avascular area was established between the FLR and contralateral lobe.

Figure 2. Contrast-enhanced computer tomography (CT) on day 28 after stage I of RALPPS depicted a clear avascular area between the diseased hemiliver and FLR, which was formed by RFA (white arrow).

Table 1. Clinical characteristics of patients undergoing RALPPS.

Characteristics	Values
Sex (male:female)	9:1
Age in years (range)	41 (33–60)
Child-Pugh score
5	9
6	1
MELD score (range)	7 (0–19)
Hepatitis B	10
Degree of Fibrosis^a
F4 (cirrhosis)	9
F3	1
Number of tumours
1 Lesion	9
2 Lesions	1
Tumour size (cm) (range)	9.2 (6.4–15.4)
Tumour type of HCC^b
Well differentiated	1
Moderately differentiated	4
Poorly differentiated	3
Portal vein tumour thrombus	4
Hepatic vein thrombosis	2

MELD: model for end-stage liver disease; HCC: hepatocellular carcinoma.

^a Classified according to the Metavir scoring system.

^b Eight patients completed both stages of operations.

Table 2. Postoperative morbidity and mortality of RALPPS.

	Stage I: n = 10	Stage II: n = 8
Complication (<IIIb)^a
Pleural effusion	0	3
Ascites	1	0
Liver dysfunction	1	1
Severe complication (≥IIIb)
Tumour metastasis	1	0
Kidney failure	0	1
PHLF	0	0
Severe pulmonary infection	0	1
Death	0	1

PHLF: post-hepatectomy liver failure.

^a According to the Clavien-Dindo classification of surgical complications.

Table 3. Postoperative liver function parameters after each stage of RALPPS.

	Preoperative	POD 3	POD 7	POD 14	POD 21	POD 28
Stage I (n = 10)
ALT (IU/l)	52.5 (18–124.5)	365.8 (172–865)	122.9 (61–211)	83.3 (33–380.7)	64.3 (27–380.7)	61.9 (18–157)
AST (IU/l)	43.4 (29–79.4)	221 (101–307)	65.8 (39–115)	54.2 (34–282.4)	49 (38–204.1)	52.3 (37–106.4)
TBIL (μmol/l)	15.0 (8.3–40.5)	21.1 (8.4–188.2)	22 (12.1–85.3)	16.4 (7.6–52.2)	23.0 (11.1–44.4)	34.0 (21.3–39.6)
PT (s)	11.8 (11–138)	13.5 (11.9–16.6)	14 (12.1–15.4)	13.1 (11.2–14.6)	14.0 (11.9–17.3)	14.1 (12–18.3)
Stage II (n = 8)
ALT (IU/l)	75 (20–137)	97.5 (41.9–615)	36.5 (16.5–155)	31.9 (24–78)	–	–
AST (IU/l)	62.5 (29–97)	59.5 (24.4–172)	28.5 (17.2–34)	32.6 (26–61)	–	–
TBIL (μmol/l)	18.0 (6.7–29.7)	17.4 (12.3–32.3)	21.2 (12.4–52.9)	30.2 (9.7–268.4)	–	–
PT (s)	12.6 (10.8–14.4)	16.0 (13.1–25.5)	16.0 (13.2–22.6)	14.4 (13.0–20.8)	–	–

RALPPS: RFA-assisted ALPPS; POD: postoperative day; ALT: alanine transaminase; AST: aspartate transaminase; TBIL: total bilirubin; PT: prothrombin time.

Table 4. Volumetric changes of the FLR and intraoperative data.

	Stage I: n = 10	Stage II: n = 8
FLR volume before operation (ml)	364 (234–606)	632 (498–736)
FLR Before Operation (%)	31 (19–37)	47 (40–58)
Blood Loss (ml)	200 (50–400)	550 (300–1000)
Operative time (min)	214 (166–270)	281 (210–487)
RFA time (min)	10 (8–15)	–
RBC transfusion (units)	–	2
Increase volume in FLR (ml)	210 (161–377)
Percentage increase In FLR (%)	53 (35–133)
Interval time (days)	28 (13–31)
Type of resection
Right hepatectomy	–	4
Extended right hepatectomy	–	1
Right trisectionectomy	–	3

FLR: future liver remnant; RFA: radio-frequency ablation; RBC: red blood cell.

Figure 3. During stage II of RALPPS, the peritoneal inflammatory response decreased and adhesions were few because the liver was not mobilised in stage I.

Table 5. Literature review.

						Stage I			Stage II
References	Type	Cases (n)	HCC (n, %)	FLR increase (%)	Interval time (days)	Duration (min)	CD ≥ IIIb (%)	Biliary leakage (%)	Duration (min)	CD ≥ IIIb (%)	Biliary leakage (%)	Overall morbidity (%)	In-hospital mortality (%)
Schnitzbauer et al. [6]	ALPPS	25	3 (12)	74	9	252	–	–	152	40^a	28^a	68	12
Gall et al. [10]	RALPPS	5	0	62.3	21.8	140	1	0	–	–	0	20	0
Schadde et al. [22]	ALPPS	202	17 (8)	80	7	327	–	–	156	–	–	28^b	9.4
Edmondson et al. [26]	RALPPS	12	–	62	21	–	0	–	–	17	–	17^c	8.3
Schadde [27]	ALPPS	48	3 (6.3)	77.4	–	–	14.6	2.1	–	27.1	20.80	41.7	7
D’Haese et al. [28]	ALPPS	35	35 (100)	47	11	293	–	–	160	26.9^a	–	62.9	5.7^d

HCC: hepatocellular carcinoma; FLR: future liver remnant; CD: Clavien-Dindo classification; CD ≥ IIIb: severe complication; RALPPS: radiofrequency-assisted ALPPS; ALPPS: associating liver partition and portal vein ligation for staged hepatectomy.

^a Includes both stages.

^b ≥CD IIIb.

^c >CD III.

^d 30-Day mortality.

Schnitzbauer AA, Lang SA, Goessmann H, et al. (2012). Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg 255:405–14.

 PubMed Web of Science ®Google Scholar

Gall TM, Sodergren MH, Frampton AE, et al. (2015). Radio-frequency-assisted Liver partition with portal vein ligation (RALPP) for liver regeneration. Ann Surg 261:e45–6.

 PubMed Web of Science ®Google Scholar

Schadde E, Ardiles V, Robles-Campos R, et al. (2014). Early survival and safety of ALPPS: first report of the International ALPPS Registry. Ann Surg 260:829–36; discussion 836–8.

 PubMed Web of Science ®Google Scholar

Edmondson MJ, Sodergren MH, Pucher PH, et al. (2016). Variations and adaptations of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS): many routes to the summit. Surgery 159:1058–72.

 PubMed Web of Science ®Google Scholar

Schadde E, Ardiles V, Slankamenac K, et al. (2014). ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors compared with conventional-staged hepatectomies: results of a multicenter analysis. World J Surg 38:1510–19.

 PubMed Web of Science ®Google Scholar

D’Haese JG, Neumann J, Weniger M, et al. (2016). Should ALPPS be used for liver resection in intermediate-stage HCC? Ann Surg Oncol 23:1335–43.

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