ALPPS and minialpps. Alternatives between liver hypertrophy techniques. Presentation of two cases in liver disease of non-colorectal origin

Abstract

Presenter: Fabio Vergara MD | IPS Universidad de Antioquia, Clinica Leon XIII Background: Liver resections are the treatment of choice for most liver tumors. Thanks to liver regeneration, various procedures have appeared to stimulate liver hypertrophy in cases where it is required. Among them is the ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy), which consists of performing a hepatectomy in two stages, achieving faster hypertrophy and in less time. This surgical technique can have high morbidity and mortality rates, so it is very important to properly select patients. In recent years, groups from Chile and Argentina have developed a variant in this technique which they have called Mini-ALPPS, where the hepatic transection is minor, thus reducing the morbidity that this part of the surgery can bring. Methods: We present two cases of ALPPS and Mini-AlPPS in liver disease of non colorectal origin. The first case of a two-stage hepatectomy using ALPPS is a 65-year-old male patient, with MRI of the abdomen shows a giant liver in the right lobe and part of segment IV compatible with probable hepatocarcinoma over non-cirrhotic liver. Hepatic volumetry show insufficient hepatic remnant, it was decided to perform an ALPPS with the aim of obtaining a faster hepatic hypertrophy. The first time was performed by laparoscopic technique, achieving right portal ligation and hepatic transection. At 10 days, a new abdominal tomography was performed to assess hypertrophy. Then proceed to the second time of the ALPPS, with an open approach. Hepatic transection is completed with right hepatic artery ligation, right bile duct control and right hepatic vein section. In the second case we used de Mini-ALLPS strategy. A 52-year-old woman with a history of resected retroperitoneal sarcoma. In the follow-up hepatic recurrence of sarcoma. MRI confirms presence of hepatic bilobar disease in the right lobe and segment IV with a single lesion in the left lateral section. It was decided to perform MiniALPPS with resection of the metastasis of the left lateral section, right portal ligation and hepatic section of 3cms deep in the firs stage. At 10 postoperative days a CT scan of the abdomen shows compensatory hypertrophy of the left lateral section. In the second stage an extended right hepatectomy was performed. Results: In the two cases the procedure was uncomplicated, did not require blood transfusion or vasopressor support, extubation and transfer to the ICU was achieved for surveillance. The ALPPS case had no signs of liver failure, he was discharged after 8 days. The pathology shows a hepatocarcinoma on non-cirrhotic liver. The MiniALPPS case has present type B postoperative liver failure, it required vasopressor support and blood transfusion. The pathology confirmed sarcoma metastases Conclusion: ALPPS and MiniALPPS are an alternative in the treatment of liver tumors where the liver remnant is insufficient. They can use when the cause of its tumor biology and we need a hypertrophy is less time or when the other ways of generating hypertrophy are failed. However, it is a procedure that can have high morbidity and mortality, so it is important to select patients in a multidisciplinary team.