‘In-Situ Split' Liver Resection/ALPPS - Historical Development and Current Practice

Abstract

Background: Liver tumors that are extensive, multifocal, or critically located frequently require advanced techniques of liver resection including ‘functional augmentation' of liver segments. Here we describe the invention and stepwise establishment of a new technique - termed ‘in-situ split' liver resection or ‘ALPPS' - enabling liver resection in certain situations. Methods: The development of the technique in the first and the subsequent 8 patients in the index center, and also the method's spread throughout Germany and the world were reviewed. Results: In 2007, in the first patient, the new technique was developed intraoperatively by necessity. Due to the convincing outcome, it was deliberately applied again several months later in another patient, and thereafter (sparsely) used for liver resection for various indications. Following oral communication, the method spread throughout Germany, and later - mainly following the publication of the initial multicentric German series - very quickly disseminated worldwide. Currently, it is used for a very (if not overly) broad spectrum of indications by many hepatobiliary surgery centers. Conclusion: In-situ split/ALPPS is a newly developed technique for liver resection, which was established for very specific situations. This method has created a hype, and is currently used rather generously by many centers worldwide.

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

“…In 2007, Prof. Hans J Schlitt [18] from Regensburg, Germany, performed, not necessarily on purpose, the first Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) procedure or, as it was and is still called in Germany the “in-situ split liver resection” in a patient with a hilar cholangiocarcinoma. This innovative concept to induce rapid hypertrophy of the FLR was soon adapted by many surgeons nationwide but was hardly recognized outside Germany [18].…”

“…This innovative concept to induce rapid hypertrophy of the FLR was soon adapted by many surgeons nationwide but was hardly recognized outside Germany [18]. In 2012, the first report of 25 cases from 5 German centers was published, including 14 patients with CRLM.…”

“…In view of this, it does not seem appropriate to consider ALPPS when an already “established” conventional surgical approach is feasible [18, 75, 77]. Thus, ALPPS is the last resort at the end of the spectrum in the treatment of CRLM, and here, where patients have no surgical alternative to ALPPS, its oncological outcome needs to be compared to modern palliative chemotherapy alone or in combination with locoregional therapy.…”

Diagnostik und Therapie des hepatozellulären Karzinoms

“…Die Hypertrophie tritt bereits innerhalb weniger Tage auf, wenn nicht nur die Pfortader ligiert, sondern auch der im Rahmen einer zweiten Operation zu resezierende Anteil der Leber bereits in diesem ersten ingri komplett von dem "gesunden" Anteil getrennt wird. Dieses erfahren wird als "in situ split" oder "associating liver partition and portal vein ligation (ALPPS) bezeichnet [8,9].…”

Frontiers of Liver Surgery

“…For this special topic of Visceral Medicine, we requested inventors of the ALPPS procedure [1] and of PVE [2] to disclose the behind-the-scenes story of invention in the light of a teaching by Confucius: 'Look for the old so as to learn the new' ( fig. 1).…”