As we all know, China is a big country of hepatitis, and liver cancer, which is caused by cirrhosis of liver and then developed into liver cancer, accounts for the third place of cancer incidence in China; because liver cancer starts insidiously and has no specific clinical symptoms, coupled with the location of liver deep under the rib arch, most of them are already in the middle and late stage when found, so the treatment effect is poor and the prognosis is not good, which is the second major cause of cancer death in China.
The current treatment methods for liver cancer include surgical resection, radiofrequency ablation, interventional therapy, liver transplantation and chemotherapy, among which the most commonly used method is surgical resection. Studies have shown that complete resection of the liver segment or lobe where the tumor is located can significantly improve the postoperative survival rate and quality of life of patients. At present, the technique of simple hepatectomy is extremely mature and postoperative complications are rare. However, only 15%-25% of patients with liver cancer can be surgically resected in China due to late diagnosis.
A very critical factor affecting surgical resection is the reserved residual liver volume (Future Liver Remnant, FLR). Future Liver Remnant (FLR) is the volume of the liver that remains after removal of the lobe where the tumor is located. In normal livers, FLR >25% must be maintained to meet the needs of the body; in patients with cirrhosis, FLR is required to be at least above 40%. Patients with less than this value for surgery are prone to postoperative complications such as liver failure and small liver syndrome, which can even endanger life safety.
Since China is a large hepatitis B country, 90% of liver cancer patients are combined with hepatitis B virus (HBV) infection, and more than 80% of them are combined with various degrees of cirrhosis, which has higher requirements for reserved residual liver volume (FLR). Currently, about 10-30% of patients are forced to forgo surgery because of insufficient reserved residual liver volume (FLR). Insufficient reserved residual liver volume (FLR) has become the key to limit the surgical resection of intermediate and advanced liver cancer, and is also the biggest challenge in the treatment of liver cancer at present.
How to promote the growth of reserved residual liver volume quickly and effectively? We know that the liver has a strong regenerative capacity, and traditional theory suggests that it takes 6 months or more for a small flap of liver to grow 50% in the body. Since the 1970s and 1980s, scholars have been experimenting new methods to promote liver regeneration, such as portal vein embolization (PVE) and portal vein ligation (PVL), but none of these methods can achieve rapid and effective promotion of regeneration of the remaining liver tissue (FLR), and often during the waiting period, patients have completely lost the chance of surgical resection due to the enlargement and metastasis of the tumor.
A procedure was first reported by German physicians Schnitzbauer et al. in 2012, and then Santibanes and Clavien et al. officially named this new procedure: two-step hepatectomy with associating liver partition and portal vein ligation ( ligation for staged hepatectomy ALPPS). Briefly, the procedure consists of two major steps. In the first step, portal vein ligation + in situ liver dissection is performed on the affected side.
By ligating the branches of the portal vein on the affected side, the blood supply to the tumor is blocked, and then the right and left lobes of the liver are completely split to isolate the blood flow between the tumor side and the healthy side. Due to the large amount of blood flow and nutrient factors entering into the liver tissue on the reserved side, the proliferation of the remaining liver tissue can be induced rapidly. In the second step, CT examination is performed one to three weeks after surgery to understand the proliferation of the remaining liver tissue and calculate the reserved residual liver volume (FLR), and radical hepatectomy is completed electively when the target value is reached. This procedure can rapidly induce the proliferation of the remaining liver tissue and increase the liver volume by 60-90% in about 1-4 weeks.
The innovative and scientific aspects of this procedure are.
(i) Ligation of the portal vein of the affected side of the liver followed by in situ dissection of the liver parenchyma between the diseased and healthy side can cause loss of portal blood flow to the affected side of the liver which in turn leads to atrophy of the affected liver lobe and exponential enlargement of the healthy side of the liver due to massive redistribution of blood supply and nutrient factors.
(ii) Due to the formation of neovascularization and the persistence of interlobular perfusion being prevented by the off-segmentation of the liver parenchyma, a high rate of remaining liver tissue augmentation can be obtained by approaching complete off-segmentation of the liver parenchyma.
(iii) Since the portal vein is ligated, this pathway of tumor metastasis via portal vein can be isolated; and the liver parenchyma is isolated, this pathway of tumor metastasis via liver parenchyma can be isolated.
④Since the liver on the affected side is not removed temporarily, the blood flow of hepatic artery and hepatic vein is still preserved, and this part of the liver will not be necrotic and can maintain certain physiological functions during the transition period to meet the needs of the body.
As with anything new, there are always disadvantages and advantages, and the same is true for the ALPPS procedure. This innovative procedure can rapidly and efficiently promote the proliferation of reserved residual liver volume (FLR), creating an opportunity for radical cure for many patients with intermediate to advanced liver cancer who would otherwise be lost to surgical resection. However, this procedure is complicated, more traumatic, with longer operation time, heavy bleeding, and many complications, and patients face two surgical blows in a short period of time, so the risk is high.
Reviewing the literature, there are few reports on ALPPS at home and abroad, and the largest number of cases is only 48. The complication rate of ALPPS is 16-64%, and the operative mortality rate is as high as 12%-23%. Bile leak is one of the most common complications after hepatectomy and often leads to abdominal infection. Especially in patients with cirrhosis, infection is often a major cause of postoperative liver failure and death. Infection has also been reported in the literature as a major cause of death. In our department, we have recently performed 7 cases of ALPPS, of which 1 case (14%) was fatal, and the cause of death was also due to liver failure caused by infection. The other 3 cases also had different degrees of abdominal infection.
At the same time, medical experts are making some efforts and attempts to minimize surgical complications while preserving the remaining liver volume reserved for efficient and rapid growth of ALPPS. For example, some scholars have tried to routinely place biliary decompression drains during stage I surgery to prevent the occurrence of bile leak secondary to abdominal infection. Some scholars try to perform the first-stage surgery under laparoscopy to minimize trauma to the patient and promote postoperative recovery; others advocate the use of hepatic tourniquet instead of hepatic parenchymal dissection, which can effectively reduce the bleeding caused by surgery to reduce postoperative complications and mortality, etc., and have achieved certain results.
Radiofrequency ablation (RFA) has been carried out in our department since the 1990s for the treatment of liver cancer, and more than 4500 cases have been completed, reaching international advanced level in clinical practice and theoretical innovation. As a proven treatment for small liver cancer, radiofrequency ablation technology is now widely used in the world. The unique thermal sealing effect of RFA (which can completely seal the blood vessels below 5mm in diameter) can be used as an adjunct to hepatectomy, i.e. to establish a bloodless band around the tumor first and then remove the tumor.
At present, we have carried out RFA-assisted hepatectomy to treat more than 300 cases of hepatocellular carcinoma combined with hepatic sclerosis, which has the characteristics of quick and easy surgery, less bleeding and fewer complications. Combining our own advantages, our department innovatively combines radiofrequency ablation (RFA) technology and ALPPS together, using RF ablation technology instead of liver parenchymal dissection method, which also establishes a complete bloodless band between diseased-healthy side liver parenchyma, and avoids the formation of liver dissection, reduces the occurrence of bile leakage and bleeding, shortens the operation time, and greatly reduces the operation complications. We named this new technique as “Radio-frequency Assisted Liver Partition with Portal vein ligation for staged hepatectomy RALPPS).
The modified RALPPS PPS procedure has the following advantages.
The procedure to avoid liver trauma and reduce bile leak and infection has the following advantages.
1. avoiding liver trauma and reducing the incidence of bile leakage and infection. Most importantly, there is no trauma to the liver during the first stage of this procedure, which completely eliminates bile leakage and effectively reduces the incidence of infection, laying a good foundation for the second stage of radical tumor resection. This is incomparable to the classical ALPPS procedure.
2. Easy to implement, less time consuming and reliable results. Combined with the “liver lift around the liver”, a complete bloodless zone can be effectively established between the diseased and healthy side of the liver. The operation time can be controlled within 1.5-3 hours, compared with 4-6 hours or even longer for the classical ALPPS. This procedure can greatly reduce the operation and anesthesia time and facilitate the patient’s recovery.
3. It reduces the technical difficulty, reduces surgical bleeding and improves safety by turning complexity into simplicity. The classical ALPPS procedure is based on the anterior approach hepatectomy technique. In the process of liver parenchymal dissection, the control of hepatic vein bleeding is a major problem, requiring the surgeon to have extremely exquisite liver surgery skills and rich experience, and the slightest carelessness may lead to uncontrollable hemorrhage. This procedure only requires the insertion of a radiofrequency needle into the liver tissue to establish the ischemic band, and the bleeding volume is only 5-10 ml during the radiofrequency coagulation, which greatly reduces the amount of surgical bleeding and improves the safety of the procedure.