A 51-year-old male was found to have a large HCC (13.5 cm x 12.5 cm x 13.8 cm) in liver segments 5-8 during a routine check-up. The patient had no clinical symptoms at the time of the diagnosis. The patient was infected with hepatitis B years ago and had stage 3 hypertension and hyperlipidemia, but not diabetes. The body weight, height, and BMI of the patient were 83 kg, 1.71 m, and 28.38 kg/m2, respectively. Laboratory tests indicated that the patient's levels of alanine transaminase (ALT; 325 U/L), alkaline phosphatase (ALP; 186 U/L), total bilirubin (TBIL; 40.0 mumol/L), direct bilirubin (DBIL; 10.3 mumol/L), creatinine (155 mumol/L), and blood ammonia (66 mumol/L) were abnormal. The alpha-fetoprotein (AFP) level was significantly increased (>800 ng/ml). The patient's liver function was grade A, with a Child-Pugh score of 6. The preoperative retention rate of ICG at 15 min was not available due to a lack of equipment in our hospital at that time. The HCC had not invaded the left lobe of the liver or adjacent/distant organs in preoperative assessment. The tumor stage was Barcelona Clinic Liver Cancer (BCLC) stage B and China liver cancer stage Ib. The estimated preoperative standard liver volume (SLV) was 1386.16 ml, and the evaluated FLR was 300 ml based on CT assessment (Figure 1). The 22% FLR/SLV was insufficient to permit the removal of the tumor in one operation with major hepatectomy; the risk of posthepatectomy liver failure (PHLF) would be too high. After a multidisciplinary team (MDT) discussion, ALPPS-based multidisciplinary treatment was planned, and the patient agreed to receive such treatment.
The surgery was performed laparoscopically. First, the gallbladder was resected. The right portal vein was separated from the hilar plate and clipped with a Hem-o-Lok (Johnson & Johnson, United States). Then, the parenchymal transection was performed via an anterior approach, following the ischemia line on the liver. Notably, intraoperative bleeding was difficult to control due to fibrosis and edema. To control the damage, the liver parenchymal tissue was only partially transected (to a point approximately 5 cm from the liver surface). Thus, it would be more appropriate to call our procedure "Mini-ALPPS." The right hepatic pedicle was sutured with black suture silk (Johnson & Johnson:Ethicon, United States). Finally, a surgical drain (Guangdong Sunlight Medical Ltd., China) was routinely placed in the hepatorenal fossa and the foramen of Winslow. The surgery required approximately 255 min and resulted in the loss of 800 ml of blood. On postoperative day (POD) 18 after stage I Mini-ALPPS, a CT was performed to re-estimate the degree of FLR hypertrophy. After evaluation, the FLR/SLV was only 34.63%; this was still not sufficient for stage II right hepatectomy. Based on this finding, we and the patient considered further interventions to facilitate FLR hypertrophy and prevent potential tumor progression during the waiting period.
After stage I surgery, a CT scan still revealed a rich arterial blood supply to the tumor. After an MDT discussion, we decided to administer TACE to the patient. On POD 22 after stage I Mini-ALPPS, TACE was performed. Hepatic angiography showed that the main arterial supply of the tumor originated from the right hepatic artery. Arterial derangement of the large tumor could also be observed. The right hepatic artery was blocked with 10 ml lipiodol mixed with 20 mg epirubicin and 20 mg lobaplatin. After chemoembolization, the arterial flow to the large tumor almost completely disappeared (Figure 2). After stage I Mini-ALPPS, CT on POD 37 revealed that the FLR/SLV had increased to 46.89%. Theoretically, the FLR/SLV now meets the requirements of stage II hepatectomy; however, due to the patient's moderate fever after TACE, stage II surgery was not performed until POD 56 after stage I surgery.
Considering the intraoperative bleeding that occurred at stage I, an open operation was planned at stage II to better control possible bleeding. Before the stage II surgery, the AFP level decreased to 126.81 ng/ml. During the surgery, we found significant hypertrophy of the left lobe of the liver. The parenchymal transection was still performed with anterior approaches. The right hepatic artery, right hepatic duct, and right portal vein were successively separated and cut after ligation with Hem-o-Lok (Johnson & Johnson, United States). The remaining liver parenchyma was then gradually dissected using an ultrasonic scalpel (Johnson & Johnson, United States) and bipolar coagulation (KANGJI Medical, China). The major vein of the right liver was separated, cut, and continuously sutured with 5-0 Prolene suture (Johnson & Johnson, United States). The right hemihepatectomy was completed after the removal of all related ligaments of the right liver. Finally, as is routine, a silicone drainage tube (Guangdong Sunlight Medical Ltd., China) was placed into the right subphrenic space. The surgery required approximately 260 min and resulted in the blood loss of 450 ml. One unit of packed red blood cells was administered, and the patient recovered without eventful complications. Histopathology confirmed a 12 cm x 9 cm x 14 cm HCC in the resected liver (Figure 3). The paracancerous liver tissues were graded as G1S1 according to the biopsy criteria of the Chinese Program of Prevention and Cure for Viral Hepatitis and graded as F1 fibrosis according to the METAVIR classification. The patient was discharged 15 days after stage II Mini-ALPPS. The patient received adjuvant transarterial chemotherapy 30 days after stage II Mini-ALPPS. 3 months later, his TBIL (40.0 mumol/L), DBIL (10.7 mumol/L), and creatinine (138 mumol/L) were still moderately elevated, but his AFP (3.94 ng/ml) was normal, and the CT scan showed no sign of residual tumor or recurrence. The patient was followed up regularly, every 3 months. After 586 days, stage II Mini-ALPPS, the patient was diagnosed with tumor recurrence (his AFP was 20.18 ng/ml, and his CT scan revealed the presence of two novel subcapsular nodules in the residual left liver and multiple metastatic nodules in the lung). The patient then received sorafenib and PD-1 inhibitor therapy. The patient has survived for 1,920 days since ALPPS surgery so far.