Skip to main content

Advertisement

SpringerLink
Log in

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastasis: the radiologist’s perspective

  • Published:
Abdominal Radiology Aims and scope Submit manuscript

Abstract

Purpose

Hepatic resection is the only potentially curative treatment for patients with colorectal liver metastasis (CRLM). Many multidisciplinary approaches, including the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, have been proposed to increase the resectability rate in these patients. ALPPS is the most recently described staged liver resection technique, representing an advantageous strategy to induce a rapid and marked increase in the future liver remnant (FLR) volume. The aim of this article is to describe the radiological evaluation of this procedure and its variation.

Methods

This retrospective study included 9 patients with CRLM who underwent the ALPPS procedure. Abdominal imaging studies were reviewed, with an emphasis on a rational radiological approach. The number of liver metastases, the FLR volume (pre- and postportal vein ligation), anatomical variations, potential pitfalls related to disease progression, and postoperative complications were evaluated.

Results

The types of hepatic resection included 4 classical ALPPS cases, 3 right ALPPS variations, and 2 left ALPPS variations. The mean FLR volume calculated in the initial evaluation was 453 mL (213–790 mL). Following the first surgery, the mean FLR volume increased to 634 mL (410–957 mL), which indicated a mean volume increase of 181.1 mL (95% CI 149.7–212.5 mL; p < 0.001) and a mean absolute volume increase of 48% (19%–88%).

Conclusion

The ALPPS procedure is an emerging form of two-stage hepatectomy. In this context, radiologists should provide crucial preoperative and perioperative information that may change surgical planning and contribute to an improvement in the oncologic outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Abbreviations

ALPPS:

Associating liver partition and portal vein ligation for staged hepatectomy

CRLM:

Colorectal liver metastasis

FLR:

Future liver remnant

IM1:

First imaging evaluation (staging imaging)

IM2:

Second imaging evaluation (recalculation of the FLR)

IM3:

Third imaging evaluation (complication assessment)

MDCT:

Multidetector computed tomography

PHLF:

Posthepatectomy liver failure

PVL:

Portal vein ligation

TLV:

Total liver volume

References

  1. Donati M, Stavrou GA, Oldhafer KJ (2013) Current position of ALPPS in the surgical landscape of CRLM treatment proposals. World J Gastroenterol 19:6548–6554. doi:10.3748/wjg.v19.i39.6548

    Article  PubMed  PubMed Central  Google Scholar 

  2. Bertens KA, Hawel J, Lung K, et al. (2015) ALPPS: challenging the concept of unresectability-a systematic review. Int J Surg 13:280–287. doi:10.1016/j.ijsu.2014.12.008

    Article  PubMed  Google Scholar 

  3. Alvarez FA, Ardiles V, Sanchez Claria R, Pekolj J, de Santibañes E (2013) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): tips and tricks. J Gastrointest Surg 17:814–821. doi:10.1007/s11605-012-2092-2

    Article  PubMed  Google Scholar 

  4. Adams RB, Aloia TA, Loyer E, et al. (2013) Selection for hepatic resection of colorectal liver metastases: expert consensus statement. HPB 15:91–103. doi:10.1111/j.1477-2574.2012.00557.x

    Article  PubMed  PubMed Central  Google Scholar 

  5. Herman P, Krüger JAP, Perini MV, Coelho FF, Cecconello I (2015) High mortality rates after ALPPS: the devil is the indication. J Gastrointest Cancer 46:190–194. doi:10.1007/s12029-015-9691-6

    Article  PubMed  Google Scholar 

  6. Li J, Girotti P, Königsrainer I, et al. (2013) ALPPS in right trisectionectomy: a safe procedure to avoid postoperative liver failure? J Gastrointest Surg 17:956–961. doi:10.1007/s11605-012-2132-y

    Article  PubMed  Google Scholar 

  7. Loos M, Friess H (2012) Is there new hope for patients with marginally resectable liver malignancies. World J Gastrointest Surg 4:163–165. doi:10.4240/wjgs.v4.i7.163

    Article  PubMed  PubMed Central  Google Scholar 

  8. De Santibañes E, Alvarez FA, Ardiles V (2012) How to avoid postoperative liver failure: a novel method. World J Surg 36:125–128. doi:10.1007/s00268-011-1331-0

    Article  PubMed  Google Scholar 

  9. Cavaness KM, Doyle MBM, Lin Y, Maynard E, Chapman WC (2013) Using ALPPS to induce rapid liver hypertrophy in a patient with hepatic fibrosis and portal vein thrombosis. J Gastrointest Surg 17:207–212. doi:10.1007/s11605-012-2029-9

    Article  PubMed  Google Scholar 

  10. Torres OJ, Fernandes ED, Oliveira CV, et al. (2012) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): a new approach in liver resections. Arq Bras Cir Dig 25:290–292

    Article  PubMed  Google Scholar 

  11. Ielpo B, Caruso R, Ferri V, et al. (2013) ALPPS procedure: our experience and state of the art. Hepato-Gastroenterology 60:2069–2075

    PubMed  Google Scholar 

  12. Vennarecci G, Laurenzi A, Sandri GL, et al. (2014) The ALPPS procedure for hepatocellular carcinoma. Eur J Surg Oncol 40:982–988

    Article  CAS  PubMed  Google Scholar 

  13. Tschuor Ch, Croome KP, Sergeant G, et al. (2013) Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion—an extension of the ALPPS approach. Eur J Surg Oncol 39:1230–1235. doi:10.1016/j.ejso.2013.08.009

    Article  PubMed  Google Scholar 

  14. Gauzolino R, Blanleuil ML (2014) Comment to the article: salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion—an extension of the ALPPS approach. Eur J Surg Oncol 40:128. doi:10.1016/j.ejso.2013.09.027

    Article  CAS  PubMed  Google Scholar 

  15. Sala S, Ardiles V, Ulla M, et al. (2012) Our initial experience with ALPPS technique: encouraging results. Updates Surg 64:167–172. doi:10.1007/s13304-012-0175-y

    Article  PubMed  Google Scholar 

  16. Schadde E, Ardiles V, Slankamenac K, et al. (2013) ALLPS is better at achieving complete resection of primarily non-resectable liver tumors compared to traditional techniques. J Am Coll Surg 217:S131. doi:10.1016/j.jamcollsurg.2013.07.304

    Article  Google Scholar 

  17. Troja A, Khatib-Chahidi K, El-Sourani N, Antolovic D, Raab HR (2014) ALPPS and similar resection procedures in treating extensive hepatic metastases: our own experiences and critical discussion. Int J Surg 12:1020–1022. doi:10.1016/j.ijsu.2014.07.006

    Article  PubMed  Google Scholar 

  18. Zhang G-Q, Zhang Z-W, Lau W-Y, Chen X-P (2014) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): a new strategy to increase resectability in liver surgery. Int J Surg 12:437–441. doi:10.1016/j.ijsu.2014.03.009

    Article  PubMed  Google Scholar 

  19. Govil S (2012) Rapid improvement in liver volume induced by portal vein ligation and staged hepatectomy: the ALPPS procedure. HPB 14:874. doi:10.1111/j.1477-2574.2012.00573.x

    Article  PubMed  PubMed Central  Google Scholar 

  20. Schadde E, Ardiles V, Robles-Campos R, et al. (2014) Early survival and safety of ALPPS: first report of the International ALPPS Registry. Ann Surg 260:829–836. doi:10.1097/SLA.0000000000000947

    Article  PubMed  Google Scholar 

  21. Machado MA, Makdissi FF, Surjan RC (2013) ALPPS procedure with the use of pneumoperitoneum. Ann Surg Oncol 20:1491–1493. doi:10.1245/s10434-013-2920-y

    Article  PubMed  Google Scholar 

  22. Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. doi:10.1097/01.sla.0000133083.54934.ae

    Article  PubMed  PubMed Central  Google Scholar 

  23. Shindoh J, Vauthey JN, Zimmitti G, et al. (2013) Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approa. J Am Coll Surg 217:126–133

    Article  PubMed  Google Scholar 

  24. Schadde E, Malagó M, Hernandez-Alejandro R, et al. (2015) Monosegment ALPPS hepatectomy: extending resectability by rapid hypertrophy. Surgery 157:676–689. doi:10.1016/j.surg.2014.11.015

    Article  PubMed  Google Scholar 

  25. Hasselgren K, Sandström P, Björnsson B, et al. (2015) Role of associating liver partition and portal vein ligation for staged hepatectomy in colorectal liver metastases: a review. World J Gastroenterol 21:4491–4498. doi:10.3748/wjg.v21.i15.4491

    PubMed  PubMed Central  Google Scholar 

  26. Jamal MH, Hassanain M, Chaudhury P, et al. (2012) Staged hepatectomy for bilobar colorectal hepatic metastases. HPB 14:782–789. doi:10.1111/j.1477-2574.2012.00543.x

    Article  PubMed  PubMed Central  Google Scholar 

  27. Lafaro KJ, Roumanis P, Demirjian AN, Lall C, Imagawa DK (2013) Gd-EOB-DTPA-Enhanced MRI for detection of liver metastases from colorectal cancer: a surgeon’s perspective! Int J Hepatol 2013:572307. doi:10.1155/2013/572307

    Article  PubMed  PubMed Central  Google Scholar 

  28. Chan VO, Das JP, Gerstenmaier JF, et al. (2012) Diagnostic performance of MDCT, PET/CT and gadoxetic acid (Primovist(®))-enhanced MRI in patients with colorectal liver metastases being considered for hepatic resection: initial experience in a single centre. Ir J Med Sci. 181:499–509. doi:10.1007/s11845-012-0805-x

    Article  CAS  PubMed  Google Scholar 

  29. Ba-Ssalamah A, Uffmann M, Saini S, et al. (2009) Clinical value of MRI liver-specific contrast agents: a tailored examination for a confident non-invasive diagnosis of focal liver lesions. Eur Radiol 19:342–357. doi:10.1007/s00330-008-1172-x

    Article  PubMed  Google Scholar 

  30. Monsky WL, Garza AS, Kim I, et al. (2011) Treatment planning and volumetric response assessment for Yttrium-90 radioembolization: semiautomated determination of liver volume and volume of tumor necrosis in patients with hepatic malignancy. Cardiovasc Intervent Radiol 34:306–318. doi:10.1007/s00270-010-9938-3

    Article  PubMed  Google Scholar 

  31. Nadalin S, Testa G, Malagó M, et al. (2004) Volumetric and functional recovery of the liver after right hepatectomy for living donation. Liver Transpl 10:1024–1029. doi:10.1002/lt.20182

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, 01308-050, Brazil

    L. C. Zattar-Ramos, R. O. Bezerra, L. T. Siqueira, D. T. Marques, M. R. Menezes, P. Herman, M. A. C. Machado, G. G. Cerri & C. C. Leite

  2. Cancer Institute of the State of São Paulo and Department of Radiology and Oncology, Medical School, University of São Paulo , São Paulo, Brazil

    R. O. Bezerra, M. R. Menezes, G. G. Cerri & C. C. Leite

  3. Department of Gastroenterology, Medical School, University of São Paulo, São Paulo, Brazil

    P. Herman

Authors
  1. L. C. Zattar-Ramos
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. R. O. Bezerra
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. L. T. Siqueira
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. D. T. Marques
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. M. R. Menezes
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. P. Herman
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. M. A. C. Machado
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. G. G. Cerri
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. C. C. Leite
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to R. O. Bezerra.

Ethics declarations

Conflict of interest

All authors declare this that there is no conflict of interest in relation to this manuscript.

Disclosures

The authors of this manuscript declare that they have no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors also state that this work has not received any funding. Institutional Review bBoard approval was obtained. W, and the need for written informed consent was waived by the Institutional Review Board.

Financial disclosures

No funding is declared.

Informed consent

The institutional review board approved this HIPAA-compliant study and waived the need for informed consent.

Research involving animal and human rights

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required. This article does not contain any studies with human participants or animals performed by any of the authors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zattar-Ramos, L.C., Bezerra, R.O., Siqueira, L.T. et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastasis: the radiologist’s perspective. Abdom Radiol 41, 2150–2160 (2016). https://doi.org/10.1007/s00261-016-0832-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00261-016-0832-6

Keywords

Search

Navigation