Abstract
PurposeHere, we analyse the technical modification of the ALPPS procedure, ligating the middle hepatic vein during the first step of the operation to enhance remnant liver hypertrophy.MethodsIn 20 of 37 ALPPS procedures, the middle hepatic vein was ligated during the first step. Hypertrophy of the functional remnant liver volume was assessed in addition to postoperative courses.ResultsVolumetric analysis showed a significant volume increase, especially for patients with colorectal metastases. Pre-existing liver parenchyma damage (odds ratio = 0.717, p = 0.017) and preoperative chemotherapy were found to be significant predictors (odds ratio = 0.803, p = 0.045) of higher morbidity and mortality. In addition, a survival benefit for maintenance of middle hepatic vein was shown.ConclusionThis technical modification of the ALPPS procedure can accentuate future liver remnant volume hypertrophy. The higher morbidity and mortality observed are most likely associated with pre-existing parenchymal damage within this group.
Highlights
The only chance for long-term tumour-free survival in patients with primary or secondary liver tumours is R0 resection [1]
If only the subgroup of patients with colorectal liver metastases was considered, the FLRV2/FLRV1 ratio was statistically significant in favour of middle hepatic vein (MHV) ligation (p = 0.028) (Table 5, Figs. 1 and 2)
Routine transection of the middle hepatic vein is not in accordance with the protocol of the initial ALPPS description. This is the first time that the effect of ligating the MHV in step 1 of the ALPPS procedure has been described in a patient series
Summary
The only chance for long-term tumour-free survival in patients with primary or secondary liver tumours is R0 resection [1]. The quality and quantity of the future liver remnant (FLRV) is the landmark for resectability. If the residual liver volume is insufficient, patients can develop smallfor-size syndrome (SFSS), which has a high risk of mortality [2, 3]. For “normal” parenchyma, an FLRV of ≥ 25% should be left. A higher FLRV (35–40%) is recommended if chronic liver parenchyma damage is present (e.g., due to chemotherapy-associated liver damage, liver fibrosis or cirrhosis) [4,5,6,7].
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