Abstract
AimTo report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature.MethodsSince January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central.ResultsUntil July 2014 ALPPS was completed in 9 patients whose mean age was 60±8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289±122 mL (21.1±5.5%) before ALPPS-1 and 528±121 mL (32.2±5.7%) before ALLPS-2 (p<0.001). The increase in FLR between the two procedures was 96±47% (range: 24–160%, p<0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8±2.9 days. The average hospital stay was 24.1±13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1±8.5 months, the overall survival was 89% at 3–6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review.ConclusionThe ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.
Highlights
Surgical resection is a potentially curative treatment for patients with primary and secondary malignant liver tumors
Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the future liver remnant (FLR)
The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors
Summary
Surgical resection is a potentially curative treatment for patients with primary and secondary malignant liver tumors. Strategies have been developed to increase the resectability of those tumors that are too advanced to be resected leaving a sufficient FLR. These strategies, namely right portal embolization (PVE) and preoperative or intraoperative ligation of the right portal vein (PVL), are based on the occlusion of the flow in one of the main branches of the portal vein (PVO) inducing atrophy in the ipsilateral liver and subsequent hypertrophy of the contralateral lobe; due to the larger volume of the right liver, usually the right branch of the portal vein is occluded to increase the volume of the left liver. In the case of fast-growing tumors, the time required to obtain compensatory hypertrophy is often too long to ensure the operability, and the degree of the compensatory hypertrophy is often lower than expected[3]
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