title: The ALPPS procedure for hepatocellular carcinoma larger than 10 centimeters.
abstract: BACKGROUND
  The only means of achieving long-term survival in hepatocellular carcinoma is complete tumor resection or liver transplantation. Patients with large hepatocellular carcinomas are currently not considered for liver transplantation. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is indicated in selected patients. We present the case of a patient with a huge hepatocellular carcinoma who underwent an ALPPS procedure.
  
  
  METHODS
  A 57-year-old man initially presented with a tumor measuring 19cm×10cm in the right lobe of the liver. The liver function was normal and there was no evidence of portal hypertension. The first part of the procedure was performed without mobilizing the liver. The middle hepatic vein was divided during parenchymal transection. The second procedure was performed after 15days. During that procedure the right hepatic artery, right bile duct, and the right hepatic vein were ligated and divided. Liver segments 4-8 with the tumor were removed. The patient developed moderate ascites but recovered after ten days. After 90days, the patient is doing well with no signs of recurrence.
  
  
  CONCLUSIONS
  Hepatocellular carcinoma is a complicated disease and ALPPS is not considered an optimal treatment option. However, patients with large tumors are not considered for liver transplantation or chemotherapy. Patients with Child-Pugh A liver disease without portal hypertension can benefit from surgical treatment for hepatocellular carcinoma; in some situations, surgery may be considerably better than other forms of treatment.
  
  
  CONCLUSIONS
  ALPPS should be considered in selected patients with large hepatocellular carcinomas.
authors.affiliation: Department of Digestive Surgery, Federal University of Maranhão, São Luiz, MA, Brazil. Electronic address: o.torres@uol.com.br.
authors.forename: Orlando Jorge M
authors.initials: OJ
authors.lastname: Torres
authors.affiliation: Department of Digestive Surgery, Federal University of Maranhão, São Luiz, MA, Brazil.
authors.forename: Rodrigo Rodrigues
authors.initials: RR
authors.lastname: Vasques
authors.affiliation: Department of Digestive Surgery, Federal University of Maranhão, São Luiz, MA, Brazil.
authors.forename: Thiago Henrique S
authors.initials: TH
authors.lastname: Silva
authors.affiliation: Department of Digestive Surgery, Federal University of Maranhão, São Luiz, MA, Brazil.
authors.forename: Miguel Eugenio L
authors.initials: ME
authors.lastname: Castelo-Branco
authors.affiliation: Department of Digestive Surgery, Federal University of Maranhão, São Luiz, MA, Brazil.
authors.forename: Camila Cristina S
authors.initials: CC
authors.lastname: Torres