Updates in Surgery

, Volume 66, Issue 1, pp 41–49 | Cite as

Defining indications to ALPPS procedure: technical aspects and open issues

  • Francesca Ratti
  • Federica Cipriani
  • Annalisa Gagliano
  • Marco Catena
  • Michele Paganelli
  • Luca Aldrighetti
Original Article
First Online:
Received:
Accepted:

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.

Keywords

Liver resection Future liver remnant Hypetrophy Portal vein ligation In situ transection ALPPS 
This is a preview of subscription content, log in to check access.

Notes

Conflict of interest

None.

References

  1. 1.
    Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, Corvera C, Weber S, Blumgart LH (2002) Improvement in perioperative outcome after hepatic resection: analysis of 1.803 consecutive cases over the past decade. Ann Surg 236(4):397–406PubMedCrossRefGoogle Scholar
  2. 2.
    Garcea G, Ong SL, Maddern GJ (2009) Predicting liver failure following major hepatectomy. Dig Liver Dis 41(11):798–806PubMedCrossRefGoogle Scholar
  3. 3.
    Shoup M, Gonen M, D’Angelica M, Jarnagin WR, DeMatteo RP, Schwartz LH, Tuorto S, Blumgart LH, Fong Y (2003) Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection. J Gastrointest Surg 7:325–330PubMedCrossRefGoogle Scholar
  4. 4.
    Ferrero A, Vigano L, Polastri R, Muratore A, Eminefendic H, Regge D, Capussotti L (2007) Postoperative liver dysfunction and future remnant liver: where is the limit? results of a prospective study. World J Surg 31:1643–1651PubMedCrossRefGoogle Scholar
  5. 5.
    Ratti F, Soldati C, Catena M, Paganelli M, Ferla G, Aldrighetti L (2010) Role of portal vein embolization in liver surgery: single centre experience in sixty two patients. Updates Surg 62(3–4):153–159PubMedCrossRefGoogle Scholar
  6. 6.
    de Baere T, Roche A, Elias D, Lasser P, Lagrange C, Bousson V (1996) Preoperative portal vein embolization for extension of hepatectomy indications. Hepatology 24:1386–1391PubMedCrossRefGoogle Scholar
  7. 7.
    Abulkhir A, Limongelli P, Healey AJ, Damrah O, Tait P, Jackson J, Habib N, Jiao L (2008) Preoperative portal vein embolization for major liver resection. A meta-analysis. Ann Surg 247:49–57PubMedCrossRefGoogle Scholar
  8. 8.
    Van Liended KP, van den Esschert JW, de Graaf W, Bipat S, Lameris JS, van Gulik TM, van Delden OM (2013) Portal vein embolization before liver resection: a systematic review. Cardiovasc Intervent Radiol 36(1):25–34CrossRefGoogle Scholar
  9. 9.
    De Santibanes E, Clavien PA (2012) Playing Play-Doh to prevent postoperative liver failure: the “ALPPS” approach. Ann Surg 255(3):415–417PubMedCrossRefGoogle Scholar
  10. 10.
    Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, Fichtner-Feigl S, Lorf T, Goralcyk A, Horbelt R, Kroemer A, Loss M, Rummele P, Scherer MN, Padberg W, Konigsrainer A, Lang H, Obed A, Schlitt HJ (2012) Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small for size settings. Ann Surg 255(3):405–414PubMedCrossRefGoogle Scholar
  11. 11.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213PubMedCrossRefGoogle Scholar
  12. 12.
    Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, Durand F (2005) The “50-50 criteria” on postoperative day 5:an accurate predictor of liver failure and death after hepatectomy. Ann Surg 242(6):824–828PubMedCrossRefGoogle Scholar
  13. 13.
    Rahbari NN, Garden OJ, Padbury R, Brooke-Smith M, Crawford M, Adam R, Koch M, Makuuchi M, Dematteo RP, Christophi C, Banting S, Usatoff V, Nagino M, Maddern G, Hugh TJ, Vauthey JN, Greig P, Rees M, Yokoyama Y, Fan ST, Nimura Y, Figueras J, Capussotti L, Buchler MW, Weitz J (2011) Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery 149(5):713–724PubMedCrossRefGoogle Scholar
  14. 14.
    Fürst G, Schulte am Esch J, Poll LW, Hosch SB, Fritz LB, Klein M, Godehardt E, Krieg A, Wecker B, Stoldt V, Stockschläder M, Eisenberger CF, Mödder U, Knoefel WT (2007) Portal vein embolization and autologous CD133 + bone marrow stem cells for liver regeneration: initial experience. Radiology 243:171–179PubMedCrossRefGoogle Scholar
  15. 15.
    Lam VW, Laurence JM, Johnston E, Hollands MJ, Pleass HC, Richardson AJ (2013) A systematic review of two-stage hepatectomy in patients with initially unresectable colorectal liver metastases. HPB 15(7):483–491PubMedCrossRefGoogle Scholar
  16. 16.
    De Santibanes E, Alvarez FA, Ardiles V (2012) How to avoid postoperative liver failure: a novel method. World J Surg 36:125–128PubMedCrossRefGoogle Scholar
  17. 17.
    Adam R, Laurent A, Azoulay D, Castaing D, Bismuth H (2000) Two stage hepatectomy: a planned strategy to treat irresectable liver tumors. Ann Surg 232(6):777–785PubMedCrossRefGoogle Scholar
  18. 18.
    Jaeck D, Oussoultzoglou E, Rosso E, Greget M, Weber JC, Bachellier P (2004) A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple an bilobar liver metastases. Ann Surg 240(6):1037–1049PubMedCrossRefGoogle Scholar
  19. 19.
    Sala S, Ardiles V, Ulla M, Alvarez F, Pekoli J, de Santibanes E (2012) Our initial experience with ALPPS technique: encouraging results. Updates Surg 64(3):167–172PubMedCrossRefGoogle Scholar
  20. 20.
    Knoefel WT, Gabor I, Rehders A, Alexander A, Krausch M, Schukte am Esch J, Fürst G, Topp SA (2013) In situ liver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection. Br J Surg 100(3):388–394PubMedCrossRefGoogle Scholar
  21. 21.
    Alvarez FA, Ardiles V, Sanchez Claria R, Pekoli J, de Santibanes E (2012) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS):tips and tricks. J Gastrointest Surg 17(4):814–821PubMedCrossRefGoogle Scholar
  22. 22.
    Li J, Girotti P, Konigsrainer I, Ladurner R, Konigsrainer A, Nadalin S (2013) ALPPS in right trisectionectomy: a safe procedure to avoid postoperative liver failure? J Gastrointest Surg 17(5):956–961PubMedCrossRefGoogle Scholar
  23. 23.
    Kokudo N, Tada K, Seki M, Ohta H, Azekura K, Ueno M, Ohta K, Yamaguchi T, Matsubara T, Takahashi T, Nakajima T, Muto T, Ikari T, Yanagisawa A, Kato Y (2001) Proliferative activity of intrahepatic colorectal metastases after preoperative hemihepatic portal vein embolization. Hepatology 34(2):267–272PubMedCrossRefGoogle Scholar
  24. 24.
    Andriani OC (2012) Long-term results with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Ann Surg 256(3):e5PubMedCrossRefGoogle Scholar
  25. 25.
    Aloia TA, Vauthey JN (2012) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): what is gained and what is lost? Ann Surg 256(3):e9PubMedCrossRefGoogle Scholar
  26. 26.
    Neuhaus P, Thelen A, Jonas S, Puhl G, Denecke T, Veltzke-Schlieker W, Seehofer D (2012) Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 19(5):1602–1608PubMedCrossRefGoogle Scholar
  27. 27.
    Yagi S, Uemoto S (2012) Small-for-size syndrome in living donor liver transplantation. Hepatobiliary Pancreat Dis Int 11(6):570–576PubMedCrossRefGoogle Scholar
  28. 28.
    Hammond JS, guha IN, Beckingham IJ, Lobo DN (2011) Prediction, prevention and management of postresection liver failure. Br J Surg 98(9):1188–1200PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2013

Authors and Affiliations

  • Francesca Ratti
    • 1
  • Federica Cipriani
    • 1
  • Annalisa Gagliano
    • 1
  • Marco Catena
    • 1
  • Michele Paganelli
    • 1
  • Luca Aldrighetti
    • 1
  1. 1.General Surgery Department, Hepatobiliary Surgery UnitIRCCS H San RaffaeleMilanItaly

Personalised recommendations