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Inverting the ALPPS paradigm by minimizing first stage impact: the Mini-ALPPS technique

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Abstract

Purpose

The current associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach is represented by an aggressive first surgical procedure followed by a shorter and less aggressive second procedure. This paradigm has been associated with high morbidity and mortality. Inverting the aggressiveness of the surgical stages might be beneficial in order to facilitate patient recovery during interval period. We propose a new technical paradigm for the ALPPS approach.

Methods

During the first stage, partial parenchymal transection combined with intraoperative portal vein embolization (PVE) was performed. Liver mobilization was kept at minimum while hilar plate or hilum dissection was strictly avoided. The completion surgery by means of the anterior approach was carried out once sufficient future liver remnant (FLR) hypertrophy and function were certified.

Results

We applied this technique in four patients (hepatocellular carcinoma in a cirrhotic liver = 1 and colorectal liver metastases = 3). The mean FLR hypertrophy was 62.6 % (range 49–79). All the four patients underwent the completion surgery with R0 margins, and neither one developed liver failure nor major complications.

Conclusions

The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage. The combination of evidence-based facts such as partial parenchymal transection, intraoperative PVE, and “non-touch” oncological rules was feasible and safe, allowing complete tumor resection in highly selected candidates with extensive liver disease.

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Abbreviations

ALPPS:

Associating liver partition and portal vein ligation for staged hepatectomy

FLR:

Future liver remnant

IPVE:

Intraoperative portal vein embolization

IOUS:

Intraoperative Doppler ultrasound

PPT:

Partial parenchymal transection

KGR:

Kinetic growth rate

PHLF:

Posthepatectomy liver failure

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Acknowledgments

The authors thank Dr. Fanny Rodriguez Santos for perfectly translating the presented technique into a wonderful drawing.

Authors’ contributions

All authors have contributed in study conception and design, acquisition of data, analysis and interpretation of data, drafting, and critical revision of manuscript.

Author information

Authors and Affiliations

  1. Hepato-Pancreato-Biliary and Liver Transplant Sections, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina

    Eduardo de Santibañes, Fernando A. Alvarez, Victoria Ardiles, Juan Pekolj & Martin de Santibañes

  2. Esmeralda 1319, 4to piso, 4to cuerpo CP 1007, Buenos Aires, Argentina

    Eduardo de Santibañes

Authors
  1. Eduardo de Santibañes
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  2. Fernando A. Alvarez
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  3. Victoria Ardiles
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  4. Juan Pekolj
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  5. Martin de Santibañes
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Corresponding author

Correspondence to Eduardo de Santibañes.

Ethics declarations

The study was approved by the hospital ethics committee, and all patients gave written informed consent for the procedure after being informed of the technique as well as its potential complications.

Conflicts of interest

The authors declare that they have no competing interests.

Source of funding

The funding involved in this work has been provided by our institution.

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de Santibañes, E., Alvarez, F.A., Ardiles, V. et al. Inverting the ALPPS paradigm by minimizing first stage impact: the Mini-ALPPS technique. Langenbecks Arch Surg 401, 557–563 (2016). https://doi.org/10.1007/s00423-016-1424-1

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  • DOI: https://doi.org/10.1007/s00423-016-1424-1

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