Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy in the Treatment of Colorectal Liver Metastases: Current Scenario

Abstract

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has expanded the surgical armamentarium for patients with advanced and bilateral colorectal liver metastases. However, the enthusiasm that the medical fraternity had about ALPPS was hampered by a high mortality rate and early and frequent tumor recurrence. While surgical safety has improved, mainly due to technical refinements and a better patient selection, the oncological value in the face of early tumor recurrence remains unclear. The only randomized controlled trial on ALPPS versus two-stage hepatectomy (TSH) so far confirmed that ALPPS led to higher resectability with comparable perioperative complication rate, but oncological outcome was not measured. Robust data regarding long-term outcome are still missing. TSH and ALPPS might be complementary strategies for the resection of colorectal liver metatsases (CRLM) with ALPPS being reserved for patients with no other surgical option, that is, after failed portal vein embolization or those with an extremely small future liver remnant. In other words, ALPPS can be considered a supplementary tool and a last resort in the liver surgeon’s hand to offer resectability in otherwise nonresectable CRLM. In these individual cases, and always embedded into a multimodal treatment setting, ALPPS may offer a chance of complete tumor removal and prolonged survival and even a chance for cure.

Current Treatment of Colorectal Liver Metastasis as a Chronic Disease

“…On the other hand, significant developments have been made in chemotherapy regimens with the intention to downsize the metastases and achieve secondary resectability. Furthermore, surgical techniques for preoperative liver volume modulation, such as PVE, PVE in combination with left vein embolization (48,49), TSH and ALPPS, have improved resectability, as described above (48).…”

Dealing with insufficient liver remnant: Associating liver partition and portal vein ligation for staged hepatectomy

“…5 In our and others' opinion, situations of performing ALPPS without previous chemotherapy should be strictly avoided today. 2,14,45,[58][59][60] This statement is supported by large cohort studies demonstrating that the vast majority of patients with CRLM (89%-98%) had neoadjuvant chemotherapy before ALPPS surgery. 2,23,61 The principle of neoadjuvant therapy applies in general to the TSH approach as 98% of patients had preoperative chemotherapy in the current LIGRO trial regardless of whether ALPPS or classical TSH was performed (Table 1).…”

Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned?

“…ALPPS has expanded the treatment options for patients with CLRM which are currently by far the main indication for this procedure (about 2/3 of patients in the ALPPS registry). 38 However, there seems to be a lack of hard criteria when ALPPS is necessary. In a recent analysis by Schnitzbauer et al 39 a tendency for potential overuse of ALPPS was assumed.…”