CHAPTER 123 - Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): Techniques

Abstract

In 2007 the first ALPPS procedure (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) was performed in Regensburg, Germany. ALPPS is a variation of two-stage hepatectomy to induce rapid liver hypertrophy allowing removal of large tumors otherwise considered irresectable due to a small future liver remnant. This operation, which is still named in situ split resection in Germany, soon attracted attention of other hepato-pancreato-biliary (HPB) centers. In 2012 the inaugural paper of 25 ALPPS procedures performed at five German HPB centers was published. In the same year, the International ALPPS Registry was created, now encountering more than 1250 cases. During the past years refinements in operative technique, in particular less invasive approaches such as partial ALPPS, tourniquet ALPPS, ablation-assisted ALPPS, hybrid ALPPS, and laparoscopic or robotic approaches, have resulted in significant improvement of safety. The most frequent indication for ALPPS is colorectal liver metastases. In a first randomized controlled study ALPPS was shown to provide a higher resectability rate than conventional two-stage hepatectomy but with similar complication rates. Long-term outcome data are still scarce. Data of the only randomized trial suggest ALPPS not to be inferior to two-stage hepatectomy. Initial results of ALPPS for hepatocellular carcinoma and perihilar cholangiocarcinoma were devastating, but with improvements in technique and better patient selection ALPPS could be a treatment alternative even in these tumors in carefully selected cases. ALPPS has enlarged the armamentarium of HPB surgeons. There is still discussion of when and how to use this novel technique that allows resection of tumors otherwise functionally irresectable.