The ALPPS Approach: Should We Sacrifice Basic Therapeutic Rules in the Name of Innovation?

Excerpt

Tolerance to extended liver resection has been dramatically improved with the development of preoperative liver volume modulation techniques using portal vein occlusion. The ALPPS approach (Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy), which associates in situ splitting to portal vein ligation, theoretically provides two main advantages compared to traditional liver volume modulation strategies. First, both enhanced portal flow deprivation in the future resected liver and accentuated inflammatory response are thought to induce faster regeneration compared to traditional strategies, and thus reduce dropout in patients with marginally resectable disease. Second, adding parenchymal transection would allow triggering liver regeneration in the future liver remnant when other classical strategies are likely to be ineffective. Hence, this strategy would appear relevant for patients with portal vein thrombosis, as recently suggested [1]. It has been almost two years since the pioneering publication of Schnitzbauer et al. [2] describing their breakthrough surgical strategy, and many centers around the world have since reported their own experience. Some reports have aimed at discussing and refining both techniques and indications, whereas others have focused on alerting readers to possible issues brought about by this audacious approach. Although much ink has flowed, most concerns have remained only speculative, and we still await midterm and long-term results. …