ALPPS Procedure. The New Frontier in Advanced Liver Surgery. Single Centre Experience and Literature Review.

Introduction: Presentation of the first experience of a liver surgery center in applying an innovative procedure - ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) for massive liver tumors. This medod has been performed in the surgery clinic 2 since 2018 in patients with massive primary or metastatic liver tumors, whose future residual liver volume is considered too small to perform curative liver resection safely. Until recently, these conditions assigned large tumors occupying more than 75-90% of the liver to the group of unresectable tumors. Prospectively, the ALPPS procedure was evaluated to convert unresectable liver tumors due to the small residual liver volume into resectable ones. Literature data were systematically reviewed using PubMed, Scopus, Google Scholar. Materials and methods: Since June 2018, 18 ALPPS procedures were performed in patients aged 62 +-8 years. Indications for surgical resection were liver metastases of colorectal cancer in 7 cases, perihilar cholangiocarcinoma in 4 cases, hepatocellular carcinoma in 6 cases, and GIST metastases 1 case. From the literature data we analyzed articles from 2014 to 2019. Results: Residual liver volume was calculated on CT angiography using the program included in the Siemens machine software and was 252 +- 115 ml (19.4 +- 6.2%) before ALPPS-1 and 542 +- 165 ml (30.7 +- 6.5%) before ALLPS-2 (P 0.001). The increase in residual liver volume between the two procedures was 60.4 +- 38% (range: 31-110%, P 0.001). The mean time between the first and second procedure was 9.4 +- 2.3 days. Average hospital stay was 28.4 +- 9.2 days. Postoperative morbidity 34.8%, mortality 0. Survival at 18 months was 100%. Conclusion: The ALPPS technique allows us to increase the resectability rate in patients with initially unresectable liver tumors with favorable postoperative outcomes. Careful selection of patients for a major complex procedure such as ALPPS allowed us to avoid postoperative mortality. Liver cirrhosis, cholestasis, and intraoperative hemorrhage are major factors for the development of postoperative morbidity.

Four Years of Hepatic Transplantation in the Republic of Moldova.

Ever since the first liver transplant in the Republic of Moldova in 2013 we have performed 30 liver transplantations, the first having been performed in collaboration with the surgical team from Romania, led by Professor Irinel Popescu. The serious deficit of available cadaveric organs has forced us to begin with right hemi-liver transplantation from a living donor. In one third of liver transplantations we used right hemi-liver graft from a living donor, and in 2/3 of cases whole liver graft was harvested from brain-dead donors. The indication for surgical intervention in most cases was hepatic cirrhosis of viral aetiology in terminal stages, three cases of hepatocellular carcinoma, and one case for each of primary biliary cirrhosis, drug-induced toxic hepatitis, and liver retransplantation caused by hepatic arterial thrombosis. 10 cadaveric grafts were harvested from elderly donors ( 65 years). In the early postoperative period, four recipients died (2 live donor graft recipients and 2 graft recipients from donors with brain death). Causes of death were: intracerebral haemorrhage in the early postoperative period - 1, acute graft rejection - 1, hepatic artery thrombosis - 1, primary graft dysfunction - 1. There were no deaths during the late postoperative period. Of the complications that occurred during the early postoperative period we can highlight acute graft rejection -2, hepatic arterial thrombosis - 1, intraabdominal postoperative haemorrhage - 1, hepatic artery thrombosis -1, biliary peritonitis - 1, primary graft dysfunction -1, seizures -1. Complications during the postoperative period: biliary peritonitis after choledochal drainage removal - 1, "small-for-size" - 2. The accumulated experience and the use of modern technologies has allowed us to reduce the postoperative mortality rate, as well as the rate of occurring complications, in order to transfer this surgical intervention from the category of exclusivity operations to the category of daily interventions.