HCC is a common and heterogeneous disease. Liver resection and transplantation are the only procedures associated with long-term survival and cure of the disease. Major liver resection is feasible in patients without cirrhosis or who have well-preserved liver function and future liver remnant of at least 25%. However, it is possible in fewer than 5% of patients. Liver transplantation is indicated in patients with a single nodule up to 5 cm in size or three nodules up to 3 cm in size each [1, 2]; though beyond Milan’s criteria, recommendations have also produced good results. For large HCC in patients without cirrhosis, resection is the only option for cure.
The limiting factor for major hepatectomy in large HCCs is inadequate FLR. There are several methods to increase the FLR to obviate the risk of post hepatectomy liver failure (PHLF), the most commonly practised being portal vein embolization (PVE) . The disadvantages of the procedure are mainly, inability to achieve adequate volume increase, delay of 4-6 weeks for the hypertrophy to occur and risk of progression of disease in this waiting period. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel technique developed in Germany by Schnitzbauer et al. . It is a two-step procedure combining parenchymal division with deportalisation of the right lobe and segment-IV in the first stage followed by completion hepatectomy in the second stage after a short interval of 7-10 days once adequate hypertrophy of FLR is achieved. The advantage is rapid and increased hypertrophy thus overcoming the disadvantages associated with PVE. It is an aggressive surgical approach for tumours considered unresectable in a single stage and an accepted alternative for a large HCC. However, it should be used selectively for patients who are not candidates for PVE due to tumour invasion of the portal vein, or as a rescue therapy after failed PVE or ligation. It can also be used as an upfront procedure and preferred over PVE in selected patients with good performance status and good liver function with HCC in a non-cirrhotic liver as in our case. It has the advantage of achieving rapid liver hypertrophy and complete tumour resection within a short interval with less incidence of post operative liver failure.
The increase in FLR volume has been reported to be between 23.8 and 200% (mean 84.16%) after an interval of 4-30 days (mean 11.6 days) between the two stages of ALPPS. In our case, there was a 14% increase in FLR after an interval of 8 days. The main drawback of ALPPS is the associated morbidity and mortality reported as 35% (range 22-90%) and 12% (range 0-28.7%) respectively [7, 8]. Increased incidence of recurrence (up to 20%) has been reported in the remnant liver, probably due to the aggressive biology of the tumour [7, 8]. However, recent results from the international ALPPS registry have shown a reduction in morbidity and mortality when performed at experienced centres. Giovanni et al. have shown that ALPPS can be performed safely in large HCC’s with acceptable overall survival and disease-free survival .