“Reversal” ALPPS in patient with hepatocellular carcinoma and liver cirrhosis. First clinical case in Russia

Liver resection in patients with HCC is the treatment of choice. In patients with insufficient future liver remnant (FLR) and compensated liver function performing the Associated Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is possible. The classic version of ALPPS consists in ligation of the right branch of the portal vein with transection of the parenchyma and then performing right hepatectomy or right trisegmentectomy. This paper describes the first case in Russia of performing ligation of the left portal branch with transection of the parenchyma and then performing left trisegmentectomy (“reversal” ALPPS) in a patient with HCC and cirrhosis. Reversal ALPPS can be successfully performed in patients with insufficient future liver remnant in well-selected patients.

ENHANCERS OF LIVER REGENERATION IN ONCOLOGICAL SURGERY

INTRODUCTION Chemotherapy hinders liver function and probably its regenerating capacity, forcing to delay it after surgery. Our objective has been to verify this effect in an experimental model and to see if a hepatotrophic agent can prevent it. MATERIAL AND METHODS Four groups of 6 WAG/RijHsd rats (males, 3-4 months) were submitted to ligation of the portal branch to the left lateral and left paramedian lobes. They were sacrificed 36 h later to quantify the percentage of liver corresponding to the ligated lobes (weight), the number of hepatocyte’s nuclei (nº/100 µm2) and their mean size (µm2). One group received no treatment (control); another folic acid (2.5 mg/kg ip, during surgery); other 5-Fluorouracil (5-FU 50 mg/kg ip 48 h before); and the fourth received folic&5-FU. RESULTS The animals treated with folic acid showed a greater number of hepatocyte’s nuclei (24.4 ± 2.77 vs 15.2 ± 1.51) and their mean size was also greater (121 ± 2.34 vs 111 ± 1.8). However, the reduction in weight of the ligated parenchyma was less than in control group (33.4 ± 1.08 vs 29.5 ± 1.08). 5-FU did not modify the number of nuclei (15.6 ± 18.4), although they were smaller in size (104 ± 1.7). The addition of folic acid to 5-FU increased the number of nuclei (21.7 ± 2.8) and normalized their size (111 ± 3.2). CONCLUSIONS 5-FU exerts a depressant effect on livers regeneration, and folic acid overcomes it. Thus, folic acid could allow early application of chemotherapy without affecting liver regeneration.

Validity of hepatic cone-unit resection for hepatocellular carcinoma.

228 Background: Anatomical liver resection (ALR) has been performed widely for hepatocellular carcinoma (HCC). However, there are difficult cases with typical ALR, due to tumor location or anatomical variation. The aim of this study is to review the cases of atypical ALR and to investigate the validity of small ALR for HCC. Methods: From 2007 to 2017, hepatic resection less than 2 segments was performed to 252 patients with HCC. (1) We reviewed cases with atypical ALR (eg. posterior segment + anterior dorsal area, S4 + S8 ventral area, etc.), and (2) Regarding the validity of cone-unite resection for single HCC, we compared the clinicopathological outcome with subsegmentectomy as a control. Results: (1) Atypical ALR was performed in 10% (17/169) of ALR less than 2 segments. There were 7 cases of extended anterior segmentectomy or extended S8 resection for patients having anterior or S8 portal branch that perfused to the right side of the right hepatic vein. Most of such atypical ALR tended to be indicated in right-side hepatectomy. (2) Liver function was well preserved in both groups, and it was better in subsegment group (ICGR15: 10.5 vs. 12.3%, ALB: 4.1 vs. 3.9g/dL). Regarding the tumor factor, the diameter was larger in the subsegment group than in the cone-unite group (2.8 vs. 2.1cm), and the proportion in which subsegmentectomy was performed in the case more than 3 cm was high (32 vs. 11%). There was no difference in OS and DFS between the two groups. Even when the tumor diameter was 3 cm or less, there was no difference in DFS between subsegment (n = 28) and cone-unite resection (n = 40). Conclusions: There are a number of cases that typical ALR is difficult, especially in the right-side hepatectomy. There was no difference in the prognosis depending on the range of resection, if HCC could be resected of subsegment or less. Therefore, depending on age and comorbidity, it is necessary to determine the type of hepatectomy without sticking to the subsegmentectomy.

Single photon emission computed tomography (SPECT) for planning of surgical tactics in advanced liver resections

Aim. To determine the indications for staged treatment in planning of advanced liver resections using SPECT. Material and methods. There were 26 patients for the period 2007–2016 who required advanced liver resections at the surgical clinic of the Botkin Hospital. Anatomic FLR (aFLR) was less than 30% in all cases that is an indication for right portal branch embolization. Two-stage treatment has been applied in 15 patients (group 1) for the period 2007–2014. Preoperative examination has included SPECT since 2015. Indication for two-stage treatment was functioning FLR (fFLR) less than 30% (group 2). The second group included 11 patients. Results. In the first group (n = 15), all patients underwent right portal branch embolization. Nine of them underwent surgery including advanced right-sided hemihepatectomy in 5 cases and right-sided hemihepatectomy in 4 cases.Acute postoperative liver failure occurred in 1 (11.1%) patient (ISGLS class A). In the second group (n = 11) need for portal embolization was determined after SPECT. In 5 patients fFLR was over 30%. Thus, advanced right-sided hemihepatectomy and conventional right-sided hemihepatectomy were carried out in 2 and 3 cases, respectively. Six patients had fFLR less than 30% and two-stage approach was indicated. Five patients underwent radical surgery: advanced right-sided hemihepatectomy and conventional right-sided hemihepatectomy were carried out in 2 and 3 cases, respectively. There were no cases of acute postoperative liver failure and mortality in this group. Conclusion. Preoperative SPECT is able to predict high risk of acute postoperative liver failure after advanced liver resection. Therefore, certain measures for prevention of this complication may be considered.