2 Stage ALPPS Liver Surgery. An Available Aggressive Surgical Option for Advanced Liver Tumors
by Dr. Iswanto Sucandy
Many patients present with a large liver tumor occupying majority of the liver lobes. The tumor can take up to 75% of the total liver volume, and only sparing 25% of healthy part. This is a condition that is often not realized by the patient, since the liver function is still preserved (compensated), despite the presence of a large liver cancer. Many medical oncologists recommend palliative chemotherapy only, since historically the treatment options are very limited. Liver transplantation is not an option due to the large tumor size, beyond the traditional transplant criteria (5cm). Without surgery, long-term survivors are simply nonexistent. Liver surgeons in Europe then developed a novel technique of two-stage ALPPS procedure liver resection in 2012 to enable a safe radical surgical resection of large liver tumors. The ALPPS liver surgery requires surgical ligation of the portal vein and liver partition to induce a rapid growth of the future liver remnant on the other side of the tumor. Removal of the gallbladder (cholecystectomy) is done as a routine part of the operation. The volume of the future liver remnant is measured before and after the first-stage, to ensure adequate growth. This ALPPS procedure liver resection is now performed laparoscopically or robotically in specialized centers such as ours to gain advantages of minimally invasive liver surgery.
In the past two years, we are seeing an increasing number of patients with very large and advanced liver cancers requiring aggressive liver resection such as the ALPPS liver surgery as the only hope for cure. Our liver surgery center in Tampa, FL has become a tertiary destination/referral center for advanced liver tumors. Without surgical resection, long-term survival is unobtainable. Most patients had been declined by other surgeons around the Tampa Bay Area and subsequently directed to only palliative chemotherapy or palliative radiologic embolization route. This type advanced liver tumors require a detailed evaluation at a high-volume liver surgery center, by a team of experienced liver surgeons, liver cancer doctor, or liver specialists. A multidisciplinary team approach (consisting of liver doctor/hepatologist, radiation oncologist, gastroenterologist, medical oncologist, and interventional radiologist) is necessary to achieve best outcomes with minimal postoperative complications.
In a recent multi-center study by Li et al., the 2 stage ALPPS procedure liver resection for intrahepatic cholangiocarcinoma (bile duct cancer within the liver) was shown to produce a superior overall survival when compared to palliative chemotherapy group*. With the aggressive ALPPS liver surgery, 3-year overall survival was 40%, while with chemotherapy only the 3-year survival was only 11%. This is clearly a significant advantage for patients who underwent the aggressive surgical approach. Complications from the ALPPS liver surgery have significantly decreased due to improvement in ALPPS surgical technique. It is therefore important for the patients to discuss with their medical oncologists about potentially available aggressive surgical option, and not simply accepting the palliative method.
In our liver surgery center in Tampa, Dr. Sucandy and his team are offering the ALPPS procedure liver resection with robotic approach using 5 small incisions and short in-hospital recovery. ALPPS liver surgery is performed for several different types of liver cancer including large hepatocellular carcinoma, colorectal liver metastasis, and perihilar cholangiocarcinoma (Klatskin’s tumor). A consultation with a liver surgeon or liver specialist is very important to explore all available surgical options, prior to accepting a noncurative option. In Tampa Bay Area and South/Central Florida, our liver surgery center is known for robotic liver resection for liver cancers, robotic bile duct cancer resection, and robotic gallbladder cancer resection, however we are also treating patients with advanced/very large liver tumors on a regular basis (either by robotic or open operation). Please do not hesitate to discuss with your medical oncologist or to contact Dr. Sucandy for potential surgical treatment of advanced/large liver tumors in Tampa Bay Area.
* Li J, Moustafa M, Linecker M, Lurje G, et al. ALPPS for Locally Advanced Intrahepatic Cholangiocarcinoma: Did Aggressive Surgery Lead to the Oncological Benefit? An International Multi-center Study. Ann Surg Oncol. 2020 May;27(5):1372-1384.