Hepatic Arterioportal Fistula Reduces The Rate Of Regeneration Of Future Liver Remnant After The First Stage Of Alpps

Objective:Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)is a novel and promising technique for radical resection of unresectable hepatobiliary malignant tumors because of inadequate volume of future liver remnant(FLR).Some patients harbor intrahepatic arterioportal fistula(APF)in liver before or after the first stage of ALPPS.However,the impact of APF on FLR regeneration and surgical complications are not known.This study aimed to clarify these issues.Methods:Consecutive patients who underwent ALPPS from March 2018to May 2019 in the First Affiliated Hospital of Guangxi Medical University were studied.Patients who had no APF before the operation but developed APF after the first stage of ALPPS were included in the APFⅠ group,patients who had APF before the first stage of ALPPS were included in the APFⅡ group,whereas patients without APF before and after the first stage of ALPPS served as the control group.Patients who underwent hepatic arterial restriction operation combined with ALPPS(HARO-ALPPS)were excluded.The rates of future liver remnant(FLR)regeneration and operative complications after the first stage of ALPPS were compared among the three groups.Results:Using the predetermined inclusion and exclusion criteria,10patients were in the APFⅠ group,15 in the APFⅡ group,10 in the control group and 10 were excluded.The rates of FLR regeneration in the APFⅠ group,APFⅡ group and control group were 126.2±83.5 cm~3(median proliferation time 12 days);202.1±112.9 cm~3(median proliferation time17.5 days);and 226.1±69.2 cm~3(median proliferative time 6 days),respectively.The kinetic growth rates(KGR)of FLR volume after the first stage of ALPPS in the APFⅠ group,APFⅡ group and control group were 11.4%±8.4%per week,6.1%±3.2%per week and 25.0%±8.8%per week,respectively.There were significant differences among the three groups(F=23.723,P<0.001).The KGR of the APFⅠ and APFⅡ groups were significantly lower than the control group(P_Ⅰ<0.001,P_Ⅱ=0.015).However,no significant difference was found in KGR between the APFⅠ and APFⅡ groups.There were no significant differences in postoperative complications among the three groups(F=2.932,P=0.817).There were significant differences among the three groups in the rates of liver failure after the first stage of ALPPS,(F=9.741,P=0.045).When compared with the control group,there was significant difference in the APFⅡ group(F=9.632,P=0.008)but not in the APFⅠ group(F=2.868,P=0.238).There were no perioperative deaths.Conclusion:APF after Stage Ⅰ ALPPS significantly reduced the rate of liver regeneration in FLR.Future studies are required to see whether treatment of APF is beneficial to patients before and after the first stage of ALPPS.