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Journal of Gastrointestinal Surgery

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01-04-2013 | How I do it

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS): Tips and Tricks

Authors: Fernando A. Alvarez, Victoria Ardiles, Rodrigo Sanchez Claria, Juan Pekolj, Eduardo de Santibañes

Published in: Journal of Gastrointestinal Surgery | Issue 4/2013

Abstract

Background

Posthepatectomy liver failure is the most severe complication after major hepatectomies and it is associated with an insufficient future liver remnant (FLR). Associating liver partition and portal vein ligation (PVL) has recently been described as a revolutionary strategy to induce a rapid and large FLR volume increase. We aim to describe our surgical technique, patient management, and preliminary results with this new two-stage approach.

Technique

During the first stage, liver partition and PVL of the diseased hemiliver are performed. The completion surgery is carried out after volumetric studies have demonstrated a sufficient FLR and provided the patient is in good condition. This is usually achieved after 7 days. In the second step, the patient undergoes a completion surgery with right hepatectomy, right trisectionectomy, or left trisectionectomy.

Results

Fifteen patients with advanced liver tumors were treated. Nine patients were males and the mean age was 54 years old. The mean difference between the preoperative and postoperative FLR volume was 303 ml (p < 0.001), which represented a mean volume increase of 78.4 %. All resections were R0. Morbidity and mortality rates were 53 and 0 %, respectively. The average hospital stay was 19 days.

Conclusions

The presented technique was feasible and safe in the hands of experienced hepatobiliary surgeons, with satisfactory short-term results. It induces rapid liver hypertrophy and at the same time it offers the possibility of cure to patients previously declared unresectable.

Agrawal S, Belghiti J. Oncologic resection for malignant tumors of the liver. Ann Surg 2011;253:656–665.PubMedCrossRef

Adam R, Laurent A, Azoulay D, Castaing D, Bismuth H. Two-stage hepatectomy: a planned strategy to treat irresectable liver tumors. Ann Surg 2000;232:777–785.PubMedCrossRef

Clavien PA, Petrowsky H, DeOliveira ML, Graf R. Strategies for safer liver surgery and partial liver transplantation. N Engl J Med 2007;356:1545–1559-8.PubMedCrossRef

de Santibañes E, Clavien PA. Playing Play-Doh to Prevent Postoperative Liver Failure. The “ALPPS” approach. Ann Surg 2012;255:415–417.PubMedCrossRef

Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, Fichtner-Feigl S, Lorf T, Goralcyk A, Hörbelt R, Kroemer A, Loss M, Rümmele P, Scherer MN, Padberg W, Königsrainer A, Lang H, Obed A, Schlitt HJ. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling two-staged extended right hepatic resection in small-for-size settings. Ann Surg 2012;255:405–14.PubMedCrossRef

Baumgart J, Lang S, Lang H. A new method for induction of liver hypertrophy prior to right trisectionectomy: a report of three cases. HPB (Oxford) 2011;13(suppl 2):1–145.

de Santibañes E, Alvarez FA, Ardiles V. How to avoid postoperative liver failure: a novel method. World J Surg 2012;36:125–128.PubMedCrossRef

Alvarez FA, Iniesta J, Lastiri J, Ulla M, Bonadeo Lassalle F, de Santibañes E. New method of hepatic regeneration. Cir Esp 2011;89:645–649.PubMedCrossRef

Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M. The Clavien–Dindo classification of surgical complications: five-year experience. Ann Surg 2009;250:187–96.PubMedCrossRef

10.

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, Büchler MW, Weitz J. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery 2011;149:713–24.PubMedCrossRef

11.

Makuuchi M, Thai BL, Takayasu K, Takayama T, Kosuge T, Gunvén P, Yamazaki S, Hasegawa H, Ozaki H. Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Surgery 1990;107:521–527.PubMed

12.

Jaeck D, Oussoultzoglou E, Rosso E, Greget M, Weber JC, Bachellier P. A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases. Ann Surg 2004;240:1037–1049.PubMedCrossRef

13.

Furrer K, Tian Y, Pfammatter T, Jochum W, El-Badry AM, Graf R, Clavien PA. Selective portal vein embolization and ligation trigger different regenerative responses in the rat liver. Hepatology 2008;47:1615–1623.PubMedCrossRef

14.

Aussilhou B, Lesurtel M, Sauvanet A, Farges O, Dokmak S, Goasguen N, Sibert A, Vilgrain V, Belghiti J. Right portal vein ligation is as efficient as portal vein embolization to induce hypertrophy of the left liver remnant. J Gastrointest Surg. 2008;12:297–303.PubMedCrossRef

15.

Heinrich S, Jochum W, Graf R, Clavien PA. Portal vein ligation and partial hepatectomy differentially influence growth of intrahepatic metastasis and liver regeneration in mice. J Hepatol 2006;45:35–42.PubMedCrossRef

16.

Elias D, De Baere T, Roche A, Ducreux M, Leclere J, Lasser P. During liver regeneration following right portal embolization the growth rate of liver metastases is more rapid than that of the liver parenchyma. Br J Surg 1999;86:784–788.PubMedCrossRef

17.

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. Proliferative activity of intrahepatic colorectal metastases after preoperative hemihepatic portal vein embolization. Hepatology 2001;34:267–272.PubMedCrossRef

18.

Clavien PA, Oberkofler CE, Raptis DA, Lehmann K, Rickenbacher A, El-Badry AM. What is critical for liver surgery and partial liver transplantation: size or quality?. Hepatology 2010;52:715–729.PubMedCrossRef

19.

Yokoyama Y, Nagino M, Nimura Y. Mechanisms of hepatic regeneration following portal vein embolization and partial hepatectomy: a review. World J Surg 2007;31:367–374.PubMedCrossRef

20.

Ding BS, Nolan DJ, Butler JM, James D, Babazadeh AO, Rosenwaks Z, Mittal V, Kobayashi H, Shido K, Lyden D, Sato TN, Rabbany SY, Rafii S. Inductive angiocrine signals from sinusoidal endothelium are required for liver regeneration. Nature 2010;468:310–5.PubMedCrossRef

21.

Clavien PA, Lillemoe KD. Note from the editors on the ALPPS e-Letters-to-the-Editor. Ann Surg 2012;256(3):552.PubMedCrossRef

Title: Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS): Tips and Tricks
Authors: Fernando A. Alvarez
Victoria Ardiles
Rodrigo Sanchez Claria
Juan Pekolj
Eduardo de Santibañes
Publication date: 01-04-2013
Publisher: Springer-Verlag
Published in: Journal of Gastrointestinal Surgery / Issue 4/2013
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-012-2092-2

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS): Tips and Tricks

Abstract

Background

Technique

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Technique

Results

Conclusions

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