Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS)

Abstract

The possibility to achieve a curative resection in patients with colorectal liver metastases (CLM) is limited by the future liver remnant (FLR), posthepatectomy liver failure (PHLF) being the most severe complication after major liver resections. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been introduced as a promising two-stage strategy to induce large FLR hypertrophy within a brief time interval. The technique consists in right portal vein ligation combined with in-situ splitting of liver parenchyma during the first stage, followed 7–10 days after by a second stage resecting the diseased hemi-liver. This short-interval two-stage strategy has been demonstrated to provide high resectability rates in patients with otherwise unresectable CLM, where almost all patients eventually benefit from a curative resection. Despite the relatively high morbidity and mortality rates reported in most series during the learning curve, recent evidence indicates that ALPPS can be performed with acceptable morbidity and mortality in experienced centers, comparable to conventional two-stage hepatectomies. In terms of oncological outcomes, the short-term results available are similar to that of conventional approaches. Therefore, it seems that ALPPS will never replace PVE for patients with a tumor-free FLR, but it might become a good option in certain cases with bilateral disease if future evidence demonstrates better or equal long-term outcomes compared with classical two-stage liver resections. Given that ALPPS is a challenging surgical innovation under development, it should be performed only at high-volume specialized centers, on patients selected by a multidisciplinary team, and included in the International ALPPS Registry.