Associating liver partition and portal vein ligation for staged hepatectomy: Indications and outcomes

Indications

The ALPPS technique has been used for almost all liver tumors with the same indications used for two-stage liver resection or PVL/PVE. The main indication to date is bilateral colorectal cancer liver metastases (CRCLMs; see Chapters 98 and 102C ); in fact, most cases of ALPPS have been performed for this indication. ^, Currently, CRCLM is the most promising indication, especially for bilobar metastases. ^, In a recent study dealing with patients from the international ALPPS registry, it has been shown that more than 15% of ALPPS procedures were done in patients who may have had no indication for a two-stage hepatectomy. Thus a tendency for potential overuse of ALPPS was observed. Hepatocellular carcinoma (HCC; see Chapter 89 ) typically arising in the cirrhotic liver (see Chapter 120 ) also has been resected by ALPPS. ^, Data from Asia are convincing but probably not reproducible elsewhere; thus these data must be interpreted with caution.

ALPPS for perihilar (PHC) and intrahepatic (IHC) cholangiocarcinoma is vigorously discussed in the surgical community, with no final agreement and a tendency to be very cautious in these indications (see Chapters 51 and 119B ). The reason for caution is the reported high mortality. ^, However, in some selected cases of cholangiocarcinoma, ALPPS may be the only operative option; it is important to remember that the first successful case was performed in a patient with PHC. If ALPPS is used in PHC, preoperative biliary drainage is advised.

The ALPPS procedure may be considered in any patient needing major liver resection in whom the FLR is deemed to be insufficient during preoperative workup (see Chapters 101 , 102B , 102C , and 119B ). When an extreme volume gain is needed, ALPPS could have an advantage over the other methods. Otherwise, when only minimal hypertrophy is necessary, PVE is the better approach in view of its lower morbidity and mortality rates. In case of tumor load in the FLR, ALPPS or classic two-stage hepatectomy is more appropriate than PVE because the FLR can be cleared of tumor during the first stage. Additionally, ALPPS should be considered in every patient in whom PVE or the classic two-stage approach is not feasible or has failed (“rescue ALPPS”). ^, Because of the higher morbidity and mortality rates, some authors advise primarily to attempt PVE and then proceed with ALPPS only when the hypertrophy response of the FLR has proved insufficient.

The combination of ALPPS with additional procedures, such as resection of the colorectal primary tumor, has been performed and represents a potential indication, although caution is advised in view of the increased surgical risk. Extrahepatic metastases, severe portal hypertension, high anesthesiologic risk, and medical contraindications to major hepatectomy constitute clear contraindications to performing this procedure, similar to other complex surgical procedures.

Assessment of future liver remnant

Assessment of FLR volume is a key determinant in planning for ALPPS; it must be performed before surgery and reevaluated before the second stage. The most widely used method is CT volumetry using thin sections (1–2 mm), preferably carried out by a radiologist together with a liver surgeon. Three-dimensional (3D) reconstructions are used to calculate the nontumorous liver volume, tumor volume, and FLR volume (see Chapters 102A , 102B , and 102C ). The limits for safe hepatic resections are usually considered from 20% to 40%, depending on the quality of liver parenchyma (fibrosis, steatosis, chemotherapy-related liver injury). On the practical level, the lower limit for FLR volume is set at 20% in patients with a normal liver, 30% to 35% in patients with chemotherapy-related liver injury, and 40% in patients with chronic liver disease. Alternatively, the more personalized standardized FLR (sFLR) volume or the ratio of FLR volume measured by CT volumetry and body weight ratio (BWR) are used. Cutoff values for proceeding to stage 2, usually after 7 to 14 days, are sFLR greater than 30% (BWR >0.5%) or 40% (BWR >0.8%) depending on parenchymal quality. Table 102D.1 summarizes degree of hypertrophy of FLR reported after stage 1. Especially in patients with hepatic comorbidities, CT volumetry may be unreliable as a predictor of function of the FLR. CT can then be complemented with an additional, quantitative liver function test such as hepatobiliary scintigraphy using technetium-99m mebrofenin. ^, This functional test has been used as a predictor of insufficient functional hypertrophy after PVE, identifying patients who are potential candidates for upfront ALPPS.

Surgical technique