Defining indications to ALPPS procedure: technical aspects and open issues

Abstract

The limit to surgical treatment of patients with hepatic tumors is represented by the proportion of residual hepatic parenchyma at the end of surgery (FLR, future liver remnant) that provides an estimation of the risk of postoperative liver failure. Recently, a new two-stage technique has been developed with the acronym (ALPPS) associating liver partitioning and portal vein ligation for staged hepatectomy with the aim of obtaining a more rapid and effective increase in FLR, even though indications are not clear yet. Between January and December 2012, eight patients were candidates to ALPPS at the Hepatobiliary Surgery Unit of San Raffaele Hospital, Milan. The first three patients (Series 1) underwent right trisectionectomy and were affected by tumors infiltrating biliary confluence, while the others (Series 2) were candidates to right hepatectomy for colorectal liver metastases. Two patients were then excluded from Series 2 because intraoperative finding of irresectable disease. Intra- and postoperative outcome was evaluated with the aim of defining indications to ALPPS. All patients reached an adequate FLR after a median of 7.5 days from the first procedure (rate of program completion 100 %). In Series 1 two patients developed complications related to bile leakage from the raw surface of the liver to be resected and septic events secondary to ischemic necrosis of the liver segment IV. One patient died following multi-organ failure secondary to sepsis. In Series 2 postoperative course was uneventful in all the patients, and in particular no patient showed disease progression between the two procedures or signs of postoperative liver failure. ALPPS approach was initially considered suitable for patients affected by Klatskin tumors who require, despite a small tumor volume, extended hepatectomies associated with surgery of the biliary tract: the analysis of this first series of patients has led to a re-evaluation of the indication to this strategy, as a consequence of encountered criticisms. Actually only a subset of patients affected by colorectal liver metastases are candidates to ALPPS.

Surgical Options in Synchronous Liver Metastases from Colorectal Cancer

“…This operation was performed until now almost exclusive in patients whose primary tumor has already been resected. It consists in initial resection of CLMs from the FLR, associated with PVL and in-situ splitting of the liver (102)(103)(104)(105)(106). It was observed that such a strategy was able to achieve a more rapid and robust hypertrophy of the FLR (107).…”

Asociación de Partición Hepática y Ligadura Portal para Hepatectomía por Etapas (ALPPS)

“…Exploración abdominal completa para asegurar que no existe carcinomatosis peritoneal (Ratti et al, 2014;Chan et al, 2015); y valorización del hígado tumoral y del remanente que quedará después de la resección (Fig. 1).…”

“…Disección del pedículo portal, esqueletizándolo y extirpando el tejido linfonodal (si aplica, dependiendo del origen de la enfermedad tumoral); y sección-ligadura de venas hepáticas accesorias (Ratti et al;Buac et al, 2016).…”

“…Sin embargo, existen otras indicaciones mucho menos frecuentes como metástasis de tumores de Wilms, ovario, cérvix uterino, estómago. GISTs y melanoma (Nadalin et al, 2014;Schadde et al, 2014a;Ratti et al;Rochet et al;Zhang et al, 2014;Hasselgren et al, 2015;Lang et al, 2015;Truant et al, 2015;Vivarelli et al, 2015;Buac et al;Björnsson et al, 2016a;Røsok et al, 2016); todo lo cual, debe estar en relación con la existencia de un hígado remanente menor de 25 % a 30 % (hígados sanos) y menor de 40 % (hígados colestásicos, esteatósicos, con fibrosis, o con cambios patológicos secundarios a quimioterapia (Nadalin et al; Ratti et al; Zhang et al; Buac et al).…”

“…Existe además, evidencia (aunque escasa), de su utilización en pacientes con cáncer de vesícula biliar metastásico, que hasta el momento es de sólo 8 casos publicados (Ratti et al;Hasselgren et al;Kremer et al, 2015;Truant et al) Fig. 4.…”