Staged liver resection for perihilar liver tumors using a tourniquet in the umbilical fissure and sequential portal vein embolization on the fourth postoperative day (a modified ALTPS). Cir Esp. 2014;92:682-686. [PMID: 25151854 DOI: 10.1016/j.ciresp.2014.07.006]

Successful treatment of a huge hepatic carcinoma with right portal vein thrombosis: A case report

INTRODUCTION

Unlike the traditional associating liver partition and portal vein ligation for staged hepatectomy, it is still controversial whether patients with portal vein thrombosis can receive benefits from liver partition.

PATIENT CONCERNS

Right upper abdominal distension for 2 months.

DIAGNOSIS

Hepatocellular carcinoma with portal vein invasion INTERVENTION:: Radiofrequency-assisted liver partition with portal vein ligation (RALPP) OUTCOMES:: Disease-free survival: 3 months, overall survival: 7 months CONCLUSION:: Our results advocate this variation of RALPP for use in patients with huge HCC with portal vein invasion, without enough future liver remnant. Patients can receive benefits from the operation, including a shorter operation time, better recovery, and lower overall costs of the 2-stage procedure.

Percutaneous radiofrequency-assisted liver partition versus portal vein embolization before hepatectomy for perihilar cholangiocarcinoma

Background

Percutaneous radiofrequency‐assisted liver partition with portal vein embolization in staged liver resection (PRALPPS) represents an alternative to portal vein embolization (PVE) followed by major liver resection in patients with perihilar cholangiocarcinoma.

Methods

This was an observational case–control study. Both procedures were applied in patients with a future liver remnant (FLR) volume of less than 40 per cent. The main end points of the study were short‐term morbidity and mortality for the two procedures. The study also compared the efficacy of the preresection phases estimated by kinetic growth rate (KGR), time interval and degree of hypertrophy of the FLR.

Results

The first phase (preresection) was completed in 11 and 18 patients, and the second phase (resection) in nine and 14 patients, in the PRALPPS and PVE groups respectively. Major morbidity after the first stage did not differ between the groups. There were no differences in blood loss, severe morbidity or liver failure rate after the second stage, with no deaths. The mean KGR of the FLR after the preresection phase for PRALPPS was 3·8 (0·6–9·8) per cent/day, and that after PVE was 1·8 (0–6·7) per cent/day (P = 0·037). The mean time interval for FLR hypertrophy in the PRALPPS and PVE groups was 15 (6–29) and 20 (8–35) days respectively (P = 0·039).

Conclusion

Short‐term outcomes were similar for PRALPPS and PVE in terms of safety. Remnant hypertrophy was achieved more rapidly by PRALPPS.

Complete or partial split in associating liver partition and portal vein ligation for staged hepatectomy: A systematic review and meta-analysis

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been adopted by liver surgeons in recent years. However, high morbidity and mortality rates have limited the promotion of this technique. Some recent studies have suggested that ALPPS with a partial split can effectively induce the growth of future liver remnant (FLR) similar to a complete split with better postoperative safety profiles. However, some others have suggested that ALPPS can induce more rapid and adequate FLR growth, but with the same postoperative morbidity and mortality rates as in partial split of the liver parenchyma in ALPPS (p-ALPPS).

AIM

To perform a systematic review and meta-analysis on ALPPS and p-ALPPS.

METHODS

A systematic literature search of PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov was performed for articles published until June 2019. Studies comparing the outcomes of p-ALPPS and ALPPS for a small FLR in consecutive patients were included. Our main endpoints were the morbidity, mortality, and FLR hypertrophy rates. We performed a subgroup analysis to evaluate patients with and without liver cirrhosis. We assessed pooled data using a random-effects model.

RESULTS

Four studies met the inclusion criteria. Four studies reported data on morbidity and mortality, and two studies reported the FLR hypertrophy rate and one study involved patients with cirrhosis. In the non-cirrhotic group, p-ALPPS-treated patients had significantly lower morbidity and mortality rates than ALPPS-treated patients [odds ratio (OR) = 0.2; 95% confidence interval (CI): 0.07–0.57; P = 0.003 and OR = 0.16; 95%CI: 0.03-0.9; P = 0.04]. No significant difference in the FLR hypertrophy rate was observed between the two groups (P > 0.05). The total effects indicated no difference in the FLR hypertrophy rate or perioperative morbidity and mortality rates between the ALPPS and p-ALPPS groups. In contrast, ALPPS seemed to have a better outcome in the cirrhotic group.

CONCLUSION

The findings of our study suggest that p-ALPPS is safer than ALPPS in patients without cirrhosis and exhibits the same rate of FLR hypertrophy.

Modifications of ALPPS - from complex to more complex or from complex to less complex operations

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy to reduce the chance of post-hepatectomy liver failure in patients with borderline or insufficient future liver remnant. ALPPS is still in an early developmental stage and its techniques have not been standardized. This study aimed to review the technical modifications of the conventional ALPPS procedure.

DATA SOURCES

Studies were identified by searching MEDLINE and PubMed for articles published from January 2007 to December 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional articles were identified by a manual search of references from key articles.

RESULTS

There have been a lot of modifications of the conventional ALPPS. These are classified as: (1) modifications aiming to improve surgical results; (2) modifications aiming to expand surgical indications; (3) salvage ALPPS; (4) ALPPS using the minimally invasive approach. Some of these modifications have made the conventional ALPPS procedure to become even more complex, although there have also been other attempts to make the procedure less complex. The results of most of these modifications have been reported in small case series or case reports. We need better well-designed studies to establish the true roles of these modifications. However, it is interesting to see how this conventional ALPPS procedure has evolved since its introduction.

CONCLUSIONS

There is a trend for the use of minimally invasive procedure in the phase 1 or 2 of the conventional ALPPS procedure. Some of these modifications have expanded the use of ALPPS in patients who have been considered to have unresectable liver tumors. The long-term oncological outcomes of these modifications are still unknown.

Modified ALPPS procedures: more safety through less invasive surgery

PURPOSE

Although associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been advocated for treating advanced liver tumors, increased morbidity and mortality remain serious problems. Many modified procedures have been devised to improve patient safety, but some confusion persists as to benefits and risks.

METHODS

Modifications to ALPPS as originally reported were reviewed to clarify their contributions to safety and their clinical relevance.

RESULTS

A variety of modifications are explained and considered. Modifications mainly aim to reduce adhesions, prevent tumor spread, avoid devascularization during liver splitting, and reduce surgical severity. Such changes aiming to increase safety and reduce invasiveness are needed to avoid high morbidity and mortality rates with this innovative procedure. However, these modified procedures still require more meaningful statistical comparisons of outcome.

CONCLUSIONS

Prospective controlled studies are needed to confirm which modified procedures should be adopted in a standardized manner as an alternative to the original ALPPS. Further, we need to further explore mechanisms of liver regeneration, functional recovery, histopathologic changes of hepatocytes, and blood distribution during ALPPS simultaneously to developing and evaluating modifications of the procedure.

Associating liver partition and portal vein ligation for staged hepatectomy: the current role and development

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient future liver remnant (FLR). ALPPS is still considered to be in an early developmental phase because surgical indications and techniques have not been standardized. This article aimed to review the current role and future developments of ALPPS.

DATA SOURCES

Studies were identified by searching MEDLINE and PubMed for articles from January 2007 to October 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional papers were identified by a manual search of references from key articles.

RESULTS

ALPPS induces more hypertrophy of the FLR in less time than portal vein embolization or portal vein ligation. The benefits of ALPPS include rapid hypertrophy 47%-110% of the liver over a median of 6-16.4 days, and 95%-100% completion rate of the second stage of ALPPS. The main criticisms of ALPPS are centered on its high morbidity and mortality rates. Morbidity rates after ALPPS have been reported to be 15.3%-100%, with ≥ the Clavien-Dindo grade III morbidity of 13.6%-44%. Mortality rates have been reported to be 0%-29%. The important questions to ask even if oncologic long-term results are acceptable are: whether the gain in quality and quantity of life can be off balance by the substantial risks of morbidity and mortality, and whether stimulation of rapid liver hypertrophy also accelerates rapid tumor progression and spread. Up till now, the documentations of the ALPPS procedure come mainly from case series, and most of these series include heterogeneous groups of malignancies. The numbers are also too small to separately evaluate survival for different tumor etiologies.

CONCLUSIONS

Currently, knowledge on ALPPS is limited, and prospective randomized studies are lacking. From the reported preliminary results, safety of the ALPPS procedure remains questionable. ALPPS should only be used in experienced, high-volume hepatobiliary centers.

Present status and future perspectives of ALPPS (associating liver partition and portal vein ligation for staged hepatectomy)

First International Consensus Meeting, Hamburg, Germany, 27-28 February 2015 More than 160 participants took part in the conference for 2 days. A total of 58 world renown experts on ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) were invited from all over the world. The faculty was divided into many different subgroups that were in contact during the 2-3 months before the conference analyzing all the most important aspects of this technique and summarizing it in a common structured work to be presented during the congress, giving final recommendations in the form of bulleted point statements. The aim was to gain a solid basis of preliminary agreement on many controversial aspects of ALPPS. A poster area was also organized with 35 posters reporting mostly mono-institutional experiences on single aspects of the technique from all five continents.

Associating liver partition and portal vein ligation for staged hepatectomy: From technical evolution to oncological benefit

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel approach in liver surgery that allows for extensive resection of liver parenchyma by inducing a rapid hypertrophy of the future remnant liver. However, recent reports indicate that not all patients eligible for ALPPS will benefit from this procedure. Therefore, careful patient selection will be necessary to fully exploit possible benefits of ALPPS. Here, we provide a comprehensive overview of the technical evolution of ALPPS with a special emphasis on safety and oncologic efficacy. Furthermore, we review the contemporary literature regarding indication and benefits, but also limitations of ALPPS.

Variations and adaptations of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS): Many routes to the summit

BACKGROUND

Our aim was to review variations from the originally described associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure and relevant clinical outcomes.

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (ie, PRISMA) guidelines. A search of PubMed and Google Scholar was conducted until March 2015. Inclusion criteria were any publications reporting technical variations and descriptions of ALPPS. Exclusion criteria were insufficient technical description, data repeated elsewhere, or data that could not be accessed in English.

RESULTS

Initial search results returned 790 results; 46 studies were included in the final qualitative analysis. There were several alternatives described to the first stage of complete parenchymal split. Variations included partial ALPPS (partial split; hypertrophy of future liver remnant [FLR] 80-90%), radiofrequency-assisted liver partition and portal vein ligation (mean FLR hypertrophy 62%), laparoscopic microwave ablation and portal vein ligation (FLR hypertrophy 78-90%), associating liver tourniquet and portal ligation for staged hepatectomy (median FLR hypertrophy 61%), and sequential associating liver tourniquet and portal ligation for staged hepatectomy (FLR hypertrophy 77%) with a potential decrease in morbidity particularly after stage I. We analyzed several other variations, including considerations for segment IV, operative maneuvers, use of laparoscopy, identification of biliary complications, and liver containment.

CONCLUSION

The current literature demonstrates a large variability in techniques of ALPPS that limits meaningful statistical comparisons of outcomes. Not physically splitting the liver at the first stage may decrease morbidity; however, randomized controlled trials are needed to determine benefits in technical variations.