Application Of Two-Stage Hepatectomy In Advanced Hepatic Alveolar Echinococcosis

Research background and purpose:Hepatic alveolar echinococcosis（HAE）is a parasitic disease similar to malignant tumor infiltration and growth.Because the onset of the disease is hidden,and patients basically have no special clinical symptoms and signs at the initial stage of infection.When many patients have clinical symptoms,the disease often has progressed to the middle and late stage,and the focus involves most areas of the liver and important liver inflow,outflow tract,and even extrahepatic metastasis,which greatly increases the difficulty of treatment.If not treated in time,the 10-year fatality rate of the disease can be as high as 94%.Up to now,radical resection combined with anti-hydatid drugs is still the first choice for HAE,but only early and a small part of middle and late HAE can be treated with radical resection.For middle and late HAE,palliative surgery combined with anti-hydatid drugs can only be used,and the therapeutic effect is not satisfactory.In recent years,with the application of ELRA in some patients with advanced HAE,a good radical effect has been achieved,and this method has gradually become a special operation for the treatment of advanced HAE.However,there are still some patients with advanced HAE who can not undergo radical surgery directly because of insufficient FLR or poor liver function with severe Budd-Chiari syndrome.Therefore,this study is to explore the choice,efficacy and safety of two-stage hepatectomy for advanced HAE patients who are not initially suitable for radical hepatectomy.Materials and Methods:The clinical data of 23 patients with advanced HAE who underwent two-stage hepatectomy from December 2016 to December 2022 were analyzed retrospectively.All the patients were not suitable for radical resection according to the evaluation of MDT at the time of admission.1.Future liver remnant（FLR）was insufficient（9 cases,FLR/SLV<35%or complicated with chronic liver disease<40%）;2.Severe Budd-Chiari syndrome（14 cases,6 cases of Child-Pugh B,8 cases of Child-Pugh C）,and no cases of FLR deficiency complicated with severe Budd-Chiari syndrome.After admission,the patients take the following measures according to the situation to create surgical conditions:1.Portal vein embolization（PVE）;2.Associating liver partition and portal vein ligation for staged hepatectomy（ALPPS）;3.Hepatic vein stent placement.Analysis of the characteristics of patients and the final efficacy and safety of different two-stage hepatectomy procedures.Result:For the patients with insufficient FLR,2 patients were treated with PVE and 7patients were treated with ALPPS stage-1.Finally,the FLR reached the standard of the second stage surgery（FLR/SLV>40%）.For 14 patients with severe Budd-Chiari syndrome,the placement of the stent in hepatic vein was performed successfully and the hepatic vein pressure was decreased（43.65±10.79 cm H₂O vs 24.63±9.79 cm H₂O）.The liver function was improved and the Child-Pugh grade was upgraded.1.The FLR/SLV of 2 patients before and after PVE were（37.85%vs 49.66%）and（33.94%vs 58.37%）respectively,and the second stage"in situ first"ex vivo liver resection and autologous liver transplantation（ELRA）was performed at intervals of 5 months and 10 months respectively.There was no significant change in liver function and no postoperative complications after the first stage PVE.After the second stage hepatectomy,1 patient developed pleural effusion,which improved after conservative treatment.In the end,2patients recovered well and were discharged after surgery,and no recurrence was found during the follow-up.2.Seven patients were treated with ALPPS,the average FLR/SLV before the first stage operation was（29.39±2.17）%,and the average FLR/SLV before the second stage operation was（50.19±2.98）%.The average increase of FLR/SLV before the first stage operation to the second stage operation was 20.8%.The difference was statistically significant（P<0.05）.The liver function indexes of all patients showed that the transaminase increased in different degrees in a short time,and the peak value of ALT reached 462（364-2426）U/L,and then decreased gradually.There was no significant difference in liver function related indexes（AST,ALT,ALB,TB,DB,PT,INR）between the 5th day after operation and the preoperative level.The interval between the first and second stages of ALPPS was（164.29±68.00）days.The average operation time of ALPPS stage-2 was（385.71±161.02）min and the intraoperative blood loss was（2128.57±664.97）ml.Intraoperative and postoperative infusion of red blood cells was（6.79±2.78）U,and fresh frozen plasma（1567.86±622.84）ml was input.Only 1 patient with Clavein-Dindo Ⅲ grade or above complication occurred after operation,and all patients recovered and discharged.3.In the 14 patients who underwent ELRA after hepatic vein stent placement,the hepatic venous pressure was significantly relieved（43.65±10.79cm H₂O vs 24.63±9.79 cm H₂O,P<0.05）.The ascites gradually decreased and the liver function improved（12 cases of Child-Pugh A,2 cases of Child-Pugh B）.No serious complications occurred during the waiting period.After the average interval of（70.07±43.71）days,second stage operation successfully performed"in situ first"ELRA procedure.The average operation time of ELRA was（13.14±1.87）h;the average intraoperative blood loss was（2128.57±664.97）ml;and the average intraoperative and postoperative infusion of red blood cells was（6.79±2.78）U and fresh frozen plasma（1567.86±622.84）ml was inpu.There was no death during the operation.Postoperative complications of grade Clavein-Dindo Ⅲ or above occurred in 3 cases,and all of them recovered and discharged after treatment.4.The postoperative follow-up period was 3 to 60 months,of which 1 patient died 8 months after operation,2 patients lost follow-up,1 patient underwent surgical resection in the third year after operation,and the other 19patients were in good living condition and there was no recurrence or death by the follow-up deadline.Conclusion:1.PVE and ALPPS are used to treat advanced HAE with insufficient FLR,which can effectively increase FLR.Hepatic vein stent placement promotes hepatic vein recanalization in patients with advanced HAE complicated with severe Budd-Chiari syndrome,which significantly improves the damaged liver function and improves the"quality"of the liver.All of the three two-stage hepatectomy measures provided good conditions for second stage radical resection for patients with unresectable advanced HAE without serious complications.2.The two-stage hepatectomy described in this study provides a new direction and form for the treatment of advanced HAE,and provides a better hope for survival for patients who have previously been identified as having only palliative resection.3.In the future,more cases are needed to summarize and analyze and further explore the clinical application effect.