ALPPS in Setting Minimally Invasive Surgery for Hepatocellular Carcinoma

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To the Editor:
We read with interest the letter-preliminary report/technique entitled “Safety of ALPPS Procedure by the Anterior Approach for Hepatocellular Carcinoma” written by Chan et al.1 The authors described their experience of 17 cases of Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) with hepatitis B-related hepatocellular carcinoma. The authors described successfully the ALPPS procedure using the “anterior approach,”—technique which was previously described by the same group.2 We agree with authors that routinely using the anterior approach for large tumors reduces the risk of iatrogenic tumor rupture during mobilization of the right tumoral liver. According to their first report of ALPPS procedure by the anterior approach,2 we proposed the association of anterior approach and liver hanging maneuver (LHM).3 In our practice, we advocated performing ALPPS using the anterior approach and LHM even in cases of hepatocellular carcinoma with major vascular invasion.4,5
In our experience of ALPPS for hepatocellular carcinoma, we observed a volume increment of future liver remnant (FLR) from 33% to 43% within 1 week; moreover, FLR volume increase continued after second ALPPS step up to 54%.6 Our results can be compared with those of Chan et al's experience1; however, in our cases, we had different etiology, and cirrhosis was hepatitis C virus (HCV), hepatitis B virus (HBV), and alcohol-related.
The authors describe an 11.8% overall morbidity (Clavien-Dindo grade III or above) and a mortality rate of 5.9% (n = 1, multiorgan failure); those results are lower than those described in the world series (28% of patients experienced severe with a perioperative 90-day mortality of 9%).
In contrast to the authors’ habit of not placing drain, plastic bag, or antiadhesive sheets, we also do not employ the plastic bag and the antiadhesive sheet. However, as previously described, it is our custom to use 2 abdominal drains between the cut surfaces of the split liver.
Nonetheless, minimal indications are continuously pushing against limits.7 Indeed, robotic major liver resection seems to display similar safety and feasibility characteristics for hepatectomies as a laparoscopic approach.8 Robotic technology can assist the hepatobiliary surgeon to perform resection of all liver segments and to perform complex hilar dissection, and also liver resections requiring biliary-enteric reconstruction.9 To sum up our comments to authors, did they believe that a minimal approach for ALPPS in the setting of cirrhotic patients could be safe? We suggested a robotic first step and a laparoscopic second step to allow for cost containment.10
In summary, it is our opinion that the ALPPS procedure may have an increasing role in the treatment of hepatocellular carcinoma, and that furthermore the use of a minimal approach may improve outcome reducing the morbidity.

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