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Efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma with macrovascular invasion: a single-center retrospective analysis

World Journal of Surgical Oncology volume 22, Article number: 260 (2024) Cite this article

Abstract

Objective The influence of macrovascular invasion on the therapeutic efficacy of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) in hepatocellular carcinoma (HCC) patients has not been previously reported. This study primarily examines the therapeutic effect of ALPPS in treating HCC with macrovascular invasion. Methods 89 patients who underwent ALPPS at the First Affiliated Hospital of Guangxi Medical University from December 2016 to December 2021 were included. Patients were categorized into three groups based on macrovascular invasion status: pure HCC, HCC with portal vein tumor thrombus (PVTT), and HCC with hepatic vein tumor thrombus (HVTT). Outcome measures such as postoperative complications, liver hyperplasia rates, and survival times were compared across the groups. Results The study comprised 44 patients without macrovascular invasion and 45 cases with it, including 37 PVTT and 8 HVTT cases. Patients with PVTT or HVTT had a higher rate of complications and liver failure after the first ALPPS stage compared to those without macrovascular invasion (P = 0.018, P = 0.036). This trend was also observed in the stratified analysis of severe complications. However, no significant differences were found in these outcomes after the second ALPPS stage among the groups. The volume and rate of future liver remnant proliferation between the two stages of ALPPS were not statistically different among the groups, with median overall survival times of 42, 39, and 33 months, and progression-free survival times of 30, 24, and 14 months, respectively (P = 0.412 and P = 0.281). Conclusion ALPPS for HCC with macrovascular invasion was considered safe, feasible, and effective, as it achieved therapeutic effects comparable to those in cases without macrovascular invasion.

Background

Primary liver cancer is one of the most prevalent malignant tumors of the digestive system, with partial hepatectomy or liver transplantation being the most effective current treatment methods [1]. Due to its insidious onset and highly invasive nature, approximately 40% of patients with advanced disease exhibit macrovascular invasion [2]. Macrovascular invasion is characterized by tumor invasion into the portal vein, hepatic vein, or even the inferior vena cava, leading to the formation of venous tumor thrombi or venous thrombosis. Traditionally, primary liver cancer with macrovascular invasion has been classified as advanced hepatocellular carcinoma (HCC), which carries a poor prognosis, and systemic palliative treatment has been considered the sole therapeutic option [3]. However, recent advancements in surgical techniques and deeper understanding of HCC have led some scholars to suggest that surgical resection may offer more significant benefits than systemic palliative treatment for HCC with macrovascular invasion [4, 5], . The success of partial hepatectomy hinges on the volume of liver remaining post-resection. An insufficient remaining liver volume can result in serious complications, such as post-hepatectomy liver failure (PHLF) [6]. There are various methods to promote the rapid proliferation of the remaining liver, such as associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), portal vein ligation (PVL), portal vein embolism (PVE). However, among these, ALPPS has been found to significantly outperform PVE/PVL in promoting the growth of the future liver remnant (FLR) [7]. Considering that patients with HCC and portal vein tumor thrombus are not suitable candidates for PVE or PVL, ALPPS has emerged as the optimal strategy for rapidly increasing the FLR in HCC cases with portal vein invasion [8].However, the impact of macrovascular invasion on the therapeutic efficacy of ALPPS in HCC patients has not been previously reported. This study, therefore, primarily investigates the impact of ALPPS on postoperative complications, residual liver volume hyperplasia, and postoperative survival time in the treatment of HCC with macrovascular invasion.

Materials and methods

Study design and ethical review

This study retrospectively collected clinical data from 89 patients who underwent ALPPS procedure in the Department of Hepatobiliary Surgery at the First Affiliated Hospital of Guangxi Medical University. The data spanned from December 2016 to December 2021 and encompassed baseline demographics, intraoperative details, postoperative clinical outcomes, and follow-up information. A schematic representation of the study design is depicted in Fig. 1. Ethical approval for this study was granted by the Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University, with the reference number (NO. 2020KY-E-111). The research was conducted in accordance with the principles of the Declaration of Helsinki. Prior to their inclusion in the study, all participants provided informed consent.

Fig. 1
figure 1

The specific design scheme of this study

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Annotation A: Comparison between two groups of patients undergoing ALPPS with portal vein tumor thrombus and those without macrovascular invasion; B: Two groups were compared between patients without macrovascular invasion and patients with hepatic vein tumor thrombus; C: Two groups were compared between patients with portal vein tumor thrombus and patients with hepatic vein tumor thrombus.

Patients’ information and grouping

The selection criteria for ALPPS in HCC patients at our research center were as follows: (1) The future liver remnant volume was less than 40% of the standard liver volume (SLV) in cases of HCC. (2) Preoperative liver function was classified as Child-Pugh Class A or B. (3) The indocyanine green clearance rate at 15 min (ICGR15) was below 10%. (4) Esophagogastric varices were present but not exceeding a moderate degree. (5) There was no evidence of extrahepatic metastasis [9].

All patients included in this study had a history of hepatitis B virus infection, with positive hepatitis B surface antigen (HBsAg) status prior to surgery. Patients underwent a comprehensive imaging evaluation consisting of at least two modalities, including spiral enhanced computed tomography (CT), doppler ultrasound, and magnetic resonance imaging (MRI). Macrovascular invasion was defined by the presence of filling defects within the portal vein, hepatic vein, or inferior vena cava on preoperative imaging, and was confirmed intraoperatively by the discovery of intraluminal tumor thrombus. For the purpose of this study, patients were categorized based on the presence of macrovascular invasion into two groups: a pure hepatocellular carcinoma group (P-HCC) and a hepatocellular carcinoma group with macrovascular invasion (MVI-HCC). Out of the 89 patients, 44 were classified as P-HCC, and 45 as MVI-HCC. Within the MVI-HCC group, there were 37 cases with portal vein tumor thrombus (PVTT) and 8 cases with hepatic vein tumor thrombus (HVTT). Notably, no patients presented with combined portal and hepatic vein tumor thrombus or tumor thrombus in the vena cava. Postoperative pathological diagnosis indicated hepatocellular carcinoma in all cases. The clinical characteristics of the three patient groups are detailed in Table 1.

Volume measurement and evaluation

Prior to and following surgery, all patients underwent spiral enhanced CT scans. The future liver remnant (FLR) was measured by trained professionals using the EDDA (IQQA) digital liver analysis software (IQQA-Liver; EDDA Technology Inc., Princeton, NJ), based on the enhanced CT data. The standard liver volume (SLV ) was calculated according to the formula : SLV = 11.508 * Kg + 334.026 [10], where “Kg” denotes body weight. The sufficiency of the FLR was assessed relative to the SLV, with different criteria applied based on the severity of liver fibrosis or cirrhosis [8]:

  • In cases of severe liver fibrosis or cirrhosis, an FLR/SLV ratio of less than 50% was deemed insufficient.

  • For mild to moderate liver fibrosis or cirrhosis, an FLR/SLV ratio below 40% was considered insufficient.

  • In the absence of liver fibrosis or cirrhosis, an FLR/SLV ratio less than 30% indicated insufficient FLR.

The decision to proceed with the second stage of the ALPPS procedure was contingent upon the FLR proliferation exceeding the aforementioned criteria post the first stage. The proliferation of FLR was quantified by its volume increase, the rate of proliferation, and the kinetic growth rate (KGR) [8, 11, 12].

Grading of post-hepatectomy liver failure and complications

The Dino-Clavien postoperative complication grading system [13]and the International Study Group of Liver Surgery (ISGLS) post-hepatectomy liver failure grading standard [14] were used to assess the classification of postoperative complications and liver failure. According to these standards, complications graded as III and IV, and liver failure classified as C, are considered severe stages, respectively.

Surgical procedure

During the initial phase of the ALPPS procedure, all patients underwent a complete transection of the liver parenchyma using the anterior approach. The second stage of the ALPPS involved performing a standard right or an extended right hepatectomy. For patients with portal vein invasion, beyond the normal surgical process in the first phase of ALPPS, it was necessary to perform an incision on the main trunk or the left branch of the portal vein to extract the cancerous thrombus and then reconstruct the blood vessel. For patients with HVTT, a similar procedure involving hepatic vein incision, thrombectomy, and reconstruction of the venous outflow tract was also required during the first phase of ALPPS.The detailed surgical process was referred to our previous literature [9].

Postoperative follow-up

Following the ALPPS procedure, all patients were required to return to the hospital for routine assessments, which included blood biochemistry, tumor markers, and imaging examinations. Postoperative follow-up was conducted through various means, including telephone, text message, or WeChat, to ensure continuous monitoring of the patients’ health status. The final follow-up date was set as December 31, 2022 For the purposes of the study, overall survival (OS) was defined as the duration from the date of surgery to the end of the follow-up period or the date of death. Progression-free survival (PFS) was defined as the time elapsed from surgery until the occurrence of recurrence, metastasis, or death.

Statistical methods

Data analysis was conducted using IBM SPSS Statistics software, version 27.0 (IBM Corp., Chicago, IL, USA). Measurement data that were normally distributed or approximately normally distributed were presented as mean ± standard deviation. For data that did not conform to a normal distribution, results were expressed as median (minimum-maximum). The count data were reported as frequency (n). Comparisons among the three groups were made using one-way analysis of variance (ANOVA) for parametric data or the Kruskal-Wallis test for nonparametric data.Kaplan-Meier method was used for survival analysis. Differences in survival outcomes were assessed with the log-rank test. A p-value of less than 0.05 was considered to indicate statistical significance.

Results

Clinical data of patients

Among the 89 patients, 44 patients with pure hepatocellular carcinoma without macrovascular invasion; there were 45 patients with hepatocellular carcinoma with macrovascular invasion, including 37 cases (82.2%) of portal vein tumor thrombus and 8 cases (17.8%) of hepatic vein tumor thrombus. Based on the classification criteria for portal vein tumor thrombus (PVTT) [15] and hepatic vein tumor thrombus (HVTT) [16], among the 37 patients with portal vein invasion, there were 4, 13, 18, and 2 cases of Vp1, Vp2, Vp3, and Vp4 types, respectively. For the 8 patients with hepatic vein invasion, there were 6 and 2 cases of Vv1 and Vv2 types, respectively, and no cases of Vv3 type were found. Comparisons of preoperative clinical data among the three groups were presented in Table 1.

Table 1 Preoperative characteristics of hepatocellular carcinoma patients with pure tumors, portal vein tumor thrombus, and hepatic vein tumor thrombus
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Surgical data of patients

Among the 89 patients who successfully underwent the first stage of ALPPS, there were no significant differences in operative time, amount of bleeding and blood transfusion across the groups with pure HCC, HCC with PVTT, and HCC with HVTT. However, statistical differences were observed in the grades of postoperative complications and liver failure among the three groups (P = 0.018 and P = 0.036). Postoperative complications were categorized into mild to moderate (grades I and II) and severe (grades III and IV). Statistical differences persisted among the patient groups (P = 0.033). The specific comparisons were detailed in Table 2.

In the second stage of ALPPS, 66 patients (74.2%) successfully completed the procedure. This included 35 cases (79.5%) with pure HCC, 25 cases (67.6%) with HCC accompanied by PVTT, and 6 cases (75%) with HVTT. No significant differences were found in the severity of postoperative complications or post-hepatectomy liver failure among the groups. There were no deaths within 30 days following both phases of ALPPS. For patients with pure HCC, those with PVTT, and those with HVTT, there were 1, 2, and 0 deaths respectively within 90 days after surgery. The detailed comparison of the three groups was presented in Table 3.

Table 2 Intraoperative and early postoperative characteristics of three hepatocellular carcinoma patient groups in the first stage of ALPPS
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Table 3 Intraoperative and postoperative outcomes for three hepatocellular carcinoma patient groups in the second stage of ALPPS
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Volume changes in patients

Following the complete ALPPS procedure, the median time between the first and second phases of ALPPS was 11 days for patients with pure HCC, 13 days for those combined with PVTT, and 9 days for those with HVTT. Despite these variations in time, there were no statistically significant differences in the amount and rate of the remaining liver regeneration among the three groups. A detailed summary of the volume changes was presented in Table 4.

Table 4 Comparative analysis of liver volume changes after the both stages of ALPPS procedure for three hepatocellular carcinoma patient groups
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Survival analysis

In the follow-up period, there were no cases of death within 30 days postoperatively. The 90-day mortality rates for the pure HCC group, the group with PVTT, and the group with HVTT were 2.3% (1/44), 5.4% (2/37), 0 (0/8), respectively. The median survival times for patients who underwent the complete ALPPS procedure were as follows: 42 months for those with pure HCC, 39 months for those combined with PVTT, and 33 months for those with HVTT. The corresponding median progression-free survival times were 30 months, 24 months, and 14 months, respectively. Patients with pure HCC, those with PVTT, and those with HVTT achieved 1-year survival rates of 82.9%, 76.0%, and 66.7%, respectively; the 2-year survival rates were 48.6%, 48.0%, and 33.3%, respectively; the 3-year survival rates were 40.0%, 28.0%, and 16.7%, respectively; and the 5-year survival rates were 14.3%, 4.0%, and 0%, respectively. Despite these differences, statistical analysis revealed no significant differences in overall survival (P = 0.412) and progression-free survival (P = 0.281) among the three groups. The survival curves illustrating these findings were presented in Fig. 2A and B.

Fig. 2
figure 2

The Surgical Procedure Flowchart. A and B represent the preoperative arterial and venous phase CT scans for a patient undergoing ALPPS, respectively; C, D, E, and F represent the preoperative volume estimation and planning 3D images, which were created using the IQQA 3D imaging system and based on enhanced CT data

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Discussion

In this study, we systematically organized and analyzed the clinical data from hepatocellular carcinoma patients who underwent ALPPS at our center. We discovered that portal vein tumor thrombus was a prevalent form of macrovascular invasion in HCC, with an incidence rate of 41.6%. This finding aligns with previous studies [17]. In contrast, hepatic vein tumor thrombus was observed less frequently, with an incidence rate of only 8.9%. Our analysis revealed that patients with macrovascular invasion experienced significantly higher grades of postoperative complications and liver failure following the first stage of ALPPS, compared to those without such invasion. However, this trend was not observed after the second stage of the procedure. Furthermore, contrary to expectations, macrovascular invasion did not exert a significant negative effect on the liver regeneration in the remaining liver tissue or on the overall survival time of the patients, when compared to cases of pure hepatocellular carcinoma (see Fig. 3).

Fig. 3
figure 3

(A) This survival curve illustrated the comparison of postoperative overall survival times among the three patient groups. the log-rank test indicated that the differences were not statistically significant (X2 = 0.673, p = 0.412). (B) This survival curve compared the postoperative progression-free survival time among the three patient groups. The log-rank test indicated that the differences were not statistically significant (X2 = 1.61, p = 0.281)

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Hepatocellular carcinoma, a common malignant tumor of the digestive tract, is most effectively treated by surgical resection. The future liver remnant (FLR) is the most critical factor limiting radical resection [6, 18]. Separating the liver parenchyma and ligating the right branch of the portal vein in the first stage of ALPPS, which stimulates the rapid proliferation of the FLR through inflammatory factors and blood flow redistribution, ensuring the safety of the second stage of ALPPS [19,20,21,22]. A study by the University of Hong Kong [7]reported a median interval of 7.5 to 14 days between the first and second stages of ALPPS for patients with hepatocellular carcinoma complicated by hepatitis. Another multicenter study categorized the liver histological risk scores and found intervals of 13 days (8–21 days) for the low-risk group and 17 days (11–32 days) for the high-risk group [23]. Lopez et al. [24] observed an approximate 60% increase in FLR within seven days post-first stage, meeting criteria for secondary surgery. Previous studies reported a median interval of 7–14 days for ALPPS stages and a 50-56.8% increase in FLR, with a second-stage completion rate of 87-91% [25, 26]. However, the average interval between the two stages of surgery involving portal vein embolization (PVE) or portal vein ligation (PVL) was 45 to 59 days, with an FLR hypertrophy rate of about 27–39% and a successful tumor resection rate of approximately 63.68–76.88% [27, 28].

In our study, the median intervals from the first to the second stage of ALPPS for groups with pure HCC, PVTT, and HVTT were 11 days, 13 days, and 9 days respectively. The completion rates for the second stage of ALPPS were 79.5%, 67.6%, 75%, respectively, with the FLR hyperplasia at about 58%, 46%, and 40%. Patients undergoing ALPPS had a significantly shorter interval between the first and second stages compared to those undergoing PVE or PVL, and their hypertrophy was also better than that of PVE or PVL. This phenomenon was consistent with the trend of previous studies [27, 29]. The proliferation rates and FLR increases were similar across groups, but lower than previously reported, possibly due to pre-existing blood flow restrictions in patients with portal or hepatic tumor thrombus. We hypothesize that these patients had increased FLR blood flow prior to the first stage, resulting in minimal hemodynamic changes and lower cytokine concentrations post-ligation. Compared to hepatocellular carcinoma patients without macrovascular invasion, those with portal or hepatic vein tumor thrombus had a slightly slower proliferation of the FLR after the first stage of ALPPS, but the difference was not statistically significant (P = 0.324). Additionally, our study’s secondary surgery completion rate was slightly lower than literature reports, potentially due to varying degrees of liver fibrosis or cirrhosis in the study population. In summary, this study indicated that macrovascular invasion did not significantly influence the proliferation rate of FLR following the first stage of the ALPPS procedure, nor did it substantially affect the completion rate of the secondary surgery.

Although the ALPPS procedure could rapidly stimulate the proliferation of the FLR within a short timeframe, thereby reducing waiting times and the risks of tumor dissemination and metastasis, the high incidence of complications and associated mortality risks were significant concerns [30, 31]. The main complications following ALPPS included bile leakage, liver failure, peritoneal effusion, and infection [32, 33]. Previous studies [34, 35]reported that the incidence of complications after the conventional ALPPS procedure ranged between 33% and 58%. In recent years, with the advancement of surgical techniques and accumulation of experience, the incidence of complications after ALPPS had decreased compared with the past, and the 90-day mortality rate of patients had also dropped from the initial 17% to about 4% [36]. In this study, the incidence of severe complications (grade III and IV) after the first and second stage of ALPPS were 24.5% and 16.7%, respectively, and the incidence of bile leakage was 2.2% and 7.6%, respectively. The above results were basically consistent with the data reported in previous studies.

Hepatocellular carcinoma with macrovascular invasion was classified as advanced hepatocellular carcinoma. Previous studies had identified that PVTT as the most common form of macrovascular invasion, occurring in up to 60% of cases, whereas HVTT had a much lower incidence of approximately 3-11% [37,38,39].In this study, the incidence rates of PVTT and HVTT were 41.6% and 9.0%, respectively, aligning with the findings in the existing literature. It had been observed that patients with macrovascular invasion, such as portal vein tumor thrombus, tend to have a higher rate of postoperative complications, ranging from 39.1 to 71.4%, which was closely associated with the classification of luminal tumor thrombus [40]. To further elucidate the impact of macrovascular invasion on postoperative complications following ALPPS, we compared HCC cases with PVTT or HVTT to those without macrovascular invasion. Our results indicated that the incidence of severe complications in patients with PVTT or HVTT was 35.1% and 25%, respectively, for the first stage, and 12% and 16.7% for the second stage. Statistical differences were observed in the incidence of severe complications and PHLF among the three groups of patients after the first stage of ALPPS (P = 0.033, P = 0.036). Severe complications, including serious liver failure, occurred more frequently in hepatocellular carcinoma cases with PVTT or HVTT, with incidence rates of 35.1% versus 11.4% and 25% versus 11.4%, respectively, showing a significant difference. However, our findings indicated that the overall incidences of severe complications following ALPPS were either on par with, or potentially lower than, the 30% complication rate reported in previous literature for PVE or PVL [27]. Additionally, further stratified analysis revealed no significant difference in the incidence of PHLF grade C between patients with macrovascular invasion and those without. Furthermore, we noted no statistical difference in the incidence of complications and PHLF among the three groups following the second stage of ALPPS. Z hang et al. [41] reported slightly higher postoperative complications after the second stage of ALPPS compared to the first stage (0–45% versus 0–25%). In this study, the incidence of serve complications after the first and second stages of ALPPS in HCC patients with PVTT was 35.1% and 12%, respectively. The incidence of serve complications after the first stage of ALPPS was higher than that of the second stage, which was inconsistent with previous literatures. We hypothesized that this discrepancy may be attributed to the additional procedures, such as incisional thrombectomy or vein reconstruction, required during the first stage of ALPPS for patients with macrovascular invasion, which could be related to the increased operative difficulty and procedural complexity. Based on these findings, we concluded that macrovascular invasion might increase the probability of serve complications after the first stage of ALPPS, but it did not appear to influence those occurring after the second stage.

What’s more, we discovered that while patients with macrovascular invasion experienced a higher incidence of severe complications after the first stage of ALPPS compared to those without such invasion, the overall postoperative complication rates across all three groups remained lower than rates reported in previous literature [42]. This reduction may be attributed to our innovative technique of mobilizing a portion of the greater omentum within the abdominal cavity to cover the liver resection area after the first ALPPS stage, potentially lowering the risk of bleeding or bile leakage, and promoting wound healing. Additionally, we made every effort to preserve the middle hepatic vein in the remaining liver, within oncological safety margins, to facilitate venous outflow, thereby reducing the pressure on the posterior circulation of the remaining liver and minimizing exudation or bleeding. Regarding preoperative assessment, we employed a combination of imaging and biochemical tests to evaluate both the volume and function of the liver.

Previous studies had confirmed that HCC combined with macrovascular invasion is a significant factor contributing to poor prognosis, and HCC was once considered a contraindication for surgery [43, 44]. Surgical treatment remained the most effective method for HCC, with the 5-year survival rate for early-stage HCC reaching 50-70%, however, when HCC progressed to an advanced stage, the 5-year survival rate significantly dropped to 10-15%, and the median survival time was only 6–8 months [43, 45, 46]. In recent years, with the decline of postoperative complications and mortality, ALPPS had emerged as the optimal choice for radical resection in high-risk HCC patients, such as those with macrovascular invasion or cirrhosis [38, 47]. Studies had shown that the median survival time for HCC patients with macrovascular invasion who underwent ALPPS was considerably longer compared to those treated with sorafenib (22 months vs. 8–10 months) [8, 48]. Chan. et al. also demonstrated that ALPPS could significantly enhance the surgical resection rate and improve long-term survival rates in HCC patients with a background of hepatitis and across various tumor stages [49]. After a median follow-up of 15 months (ranging from 2 to 66 months), we observed that the median survival times for patients with pure HCC, PVTT, and HVTT were 42 months, 39 months, and 33 months, respectively. Additionally, the median progression-free survival times were 30 months, 24 months, and 14 months, respectively, aligning with previous literature. The study results indicated that ALPPS provided superior long-term survival outcomes for patients with unresectable HCC compared to those achieved with PVE [50]. While the survival times for patients with PVTT or HVTT were shorter than those with pure HCC, these differences were not statistically significant.

In conclusion, we found that the presence of PVTT or HVTT in patients with HCC may have increased the risk of severe complications after the first stage of ALPPS, but it did not appear to influence the incidence of complications during the second phase, the rate of liver hyperplasia between the two stages, or postoperative survival times. For HCC patients with macrovascular invasion, ALPPS could have achieved relatively favorable outcomes through careful preoperative patient selection and evaluation, meticulous intraoperative procedures, and comprehensive postoperative care. However, this study was a retrospective and single-center study with a limited number of cases, which may have introduced a degree of selection bias that could have affected the conclusions. Future studies should combine multiple centers and increase the sample size to reduce bias, and potentially conduct clinical randomized controlled trials to further verify the conclusions of this research.

Conclusion

Hepatocellular carcinoma with macrovascular is not necessarily a contraindication for ALPPS. Although the presence of PVTT or HVTT may increase the incidence of severe complications following the first stage of ALPPS, it does not affect the incidence of complications after the second stage of ALPPS, the rate of FLR proliferation, and survival times. ALPPS has been shown to provide substantial therapeutic advantages for HCC patients, irrespective of the presence of macrovascular invasion. It has proven to be a safe, viable, and efficacious treatment approach for HCC, even in cases complicated by macrovascular invasion.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author (sunxuyong@gxmu.edu.cn) upon reasonable request. Data are located in controlled access data storage at the First Affiliated Hospital of Guangxi Medical University.

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Funding

This study was supported by the High-Level Medical Expert Training Program of Guangxi “139” Plan Funding (G202002016) and the National Natural Science Foundation of China (No. 81560387).

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Author notes

  1. Chunhui Ye and Meifang Ou contributed equally to this work.

Authors and Affiliations

  1. The Medicine Center of Transplantation, the Second Affiliated Hospital of Guangxi Medical University, Nanning, 530000, China

    Chunhui Ye & Xuyong Sun

  2. The Medical Research Center of Organ Transplantation of Guangxi province, Nanning, 530000, China

    Chunhui Ye & Xuyong Sun

  3. The Key Laboratory of Organ Donation and Transplantation of Guangxi province, Nanning, 530000, China

    Chunhui Ye & Xuyong Sun

  4. Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, China

    Meifang Ou, Zhang Wen, Banghao Xu & Ya Guo

  5. Department of Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, China

    Tingting Lu

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  1. Chunhui Ye
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Contributions

Dr Ye: data analysis and interpretation and drafting of the manuscript MS Ou: data analysis and interpretation and drafting of the manuscript Dr Wen: conception and design and interpretation of the manuscriptDr Xu: data acquisition and revising of the manuscript MS Lu: data acquisition, analysis, and interpretation Dr Guo: data acquisition and critical revision of the manuscript Dr Sun: conception and design, data analysis, and revising of the manuscript.

Corresponding author

Correspondence to Xuyong Sun.

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This study was in accordance with the Declaration of Helsinki and approved by the Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University (NO. 2020KY-E-111). Informed consent was obtained from all patients before the study.

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Ye, C., Ou, M., Wen, Z. et al. Efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma with macrovascular invasion: a single-center retrospective analysis. World J Surg Onc 22, 260 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12957-024-03538-8

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Keywords

World Journal of Surgical Oncology

ISSN: 1477-7819

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