Associated liver partition and portal vein ligation for staged hepatectomy: a review

Abstract

Outcomes of liver resection have improved with advances in surgical techniques, improvements in critical care and expansion of resectability criteria. However, morbidity and mortality following liver resection continue to plague surgeons. Post-hepatectomy liver failure (PHLF) due to inadequate future liver remnant (FLR) is an important cause of morbidity and mortality following liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-staged procedure described in 2012, which aims to induce rapid hypertrophy of the FLR unlike conventional two-stage hepatectomy, which require a longer time for FLR hypertrophy. Careful patient selection and modifications in surgical technique has improved morbidity and mortality rates in ALPPS. Colorectal liver metastases (CRLM) confers the best outcomes post-ALPPS. Patients <60 years old and low-grade fibrosis with underlying hepatocellular carcinoma (HCC) are also eligible for ALPPS. Evidence for other types of cancers is less promising. Current studies, though limited, demonstrate that ALPPS has comparable oncological outcomes with conventional two-stage hepatectomy. Modifications such as partial-ALPPS and mini-ALPPS have shown improved morbidity and mortality compared to classic ALPPS. ALPPS may be superior to conventional two-stage hepatectomy in carefully selected groups of patients and has a promising outlook in liver surgery.

Ligation of the middle hepatic vein to increase hypertrophy induction during the ALPPS procedure

“…The processing of our data revealed completion with the second step after an average of 9 days, though it must be noted that an average of 9–14 days is reported in the literature [ 26 ]. Our cohort showed an average time advantage for the MHV ligation group of 8.5 days.…”

Laparoscopic ICG-guided ralpps procedure for HCC on cirrhosis with 3D reconstruction implementation: a case report

“…To guarantee both a complete resection and an adequate venous drainage, a right hepatectomy was deemed necessary. As previously described in several reports [21,22] a preservation of at least 30% of liver volume in a healthy liver is necessary to avoid PHLF, and this fraction rises to 40% when cirrhosis or cholestasis is present. A two-stage hepatectomy was excluded because compared to PVE and ALPPS, it is associated with a lower regenerative power and a higher dropout rate [23,24] .…”

Portal and hepatic vein embolization prior to major hepatectomy

“…Thus, future studies should also include longitudinal assessment of liver function in response to PHVE and HVE, for example with the methods that have been described for functional tests prior and after PVE [3,31]. Moreover, studies investigating the potential of PHVE and HVE in comparison to other approaches to induce FRL hypertrophy, such as associated liver partition and portal vein ligation for staged hepatectomy (ALPPS), radioembolization or transarterial chemoembolization are needed [31][32][33][34][35].…”