Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): a new strategy to increase resectability in liver surgery

Background: Partial hepatectomy with clear surgical margins is the main curative treatment for hepatic malignancies. The safety of liver resection, to a great extent, depends on the volume of future liver remnant. This manuscript reviews some important strategies that have been developed to increase resectability for patients with borderline volume of future liver remnant, particularly associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).

Methods: To identify potentially relevant articles, we searched Medline and PubMed from January 2010 to December 2013 using the keywords "Associating liver partition and portal vein ligation for staged hepatectomy", "ALPPS", "portal vein embolization", "future liver remnant", "liver hypertrophy", and "liver failure". A number of references from the key articles were also cited. There were no exclusion criteria for published information to the topics.

Results: Portal vein ligation (PVL) or embolization (PVE) are traditional approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, about 14 percent of patients fail to this approach. Adequate hypertrophy of the FLR using PVL or PVE generally takes more than four weeks. ALPPS can induce rapid growth of the FLR, which is more effective than by portal vein embolization or occlusion alone. Reportedly, the hypertrophy extent of FLR was 40%-80% within 6-9 days in contrast to approximately 8%-27% within 2-60 days by PVL/PVE. However, ALPPS was reported to have high operative morbidity (16%-64% of patients), mortality (12%-23% of patients) and bile leakage rates. Bile leakage and sepsis remain a major cause of morbidity, and the main cause of mortality includes hepatic insufficiency.

Conclusion: ALPPS has emerged as a new strategy to increase resectability of hepatic malignancies. Due to high morbidity and mortality rates of ALPPS procedure, the surgical candidates should be selected carefully. Moreover, there are very limited available evidence for its technical feasibility, safety and oncological outcome which are needed for further evaluation in larger scale of studies.