ccc surgery

1. Οriginal
Paper
51
LIVER
ABSTRACT
Background/Aims: The majority of the time
extended liver resections cannot be realized because
of an insufficient future remnant liver. Baumgart
suggests recently combining liver partition and
portal vein section for staged hepatectomy, named
ALPPS procedure. Our aim is to share our initial
experience with ALPPS procedure and to perform
the first comprehensive English literature review.
Methodology: From January 2011 until June 2013,
6 patients underwent ALPPS, performing 6 extended
right hepatectomies (one with concomitant right
colectomy, one with main biliary duct resection).
Results: The present series showed a mean of
110% volume hypertrophy of the future remnant
liver achieved with a mean of 15.3 days after ALPPS.
One patient experienced severe liver failure, one
had biliary leak and one died for postoperative
respiratory distress syndrome. After a mean follow-
up of 16.2 months (range 2–30 months) one patient
had liver recurrence. In an English literature
search, we identified 18 publications describing a
mean hypertrophy rate of 85%, a mean morbidity
and mortality rate of 35% and 6%, respectively.
Conclusions: ALPPS is an effective technique used to
induce an increased and rapid growth of the future
remnant liver, but at the price of a higher morbidity
and mortality compared with other conventional
procedures.
Key Words:
Liver tumors;
Hepatectomy;
Liver failure;
ALPPS
Hepato-Gastroenterology 2013; 60:00-00 doi 10.5754/hge 13583
© H.G.E. Update Medical Publishing S.A., Athens
ALPPS Procedure: Our Experience and
State of the Art
Benedetto Ielpo, Riccardo Caruso, Valentina Ferri, Yolanda Quijano, Hipolito Duran, Eduardo Diaz,
Isabel Fabra, Catalina Oliva, Sergio Olivares, José Carlos Plaza and Emilio Vicente
Sanchinarro University Hospital, Madrid, Spain
Corresponding author: Benedetto Ielpo, Sanchinarro University Hospital, Calle Oña 10,
28050, Madrid, Spain; Tel.: +34-9175-67800, Fax: +34-9175-00455; E-mail: ielpo.b@gmail.com
INTRODUCTION
Radical resection remains the most effective
treatment for primary and metastatic liver
malignancies. Although this treatment is associated
with long-term survival rate, only 10% of patients
with hepatocarcinoma and 25% with liver metastases
are suitable to undergo surgical resection [1].
Major liver resection has a major complication
represented by post-operative liver insufficiency.
The remnant liver volume should be no less than
25% of the total liver volume in order to minimize the
risk of this complication. Most of these patients are
under neo-adjuvant therapy line, therefore, they are
more likely to present with mild liver insufficiency. In
these cases, a minimum of 40% of the liver should be
preserved [2]. Several therapeutic strategies have
been developed in order to render initially non-
resectable tumors, resectable, including portal vein
embolization/ligation, “two stage” liver resection, and
surgery combined with loco-regional therapies [3].
A novel procedure was introduced two years ago
by Baumgart, generating increasing interest [4]. It
consists in associating liver partition with portal vein
ligation for staged hepatectomy (ALPPS). It provides
a rapid future liver remnant (FLR) hypertrophy and
a number of cases have been reported up to now,
in only 2 years. However, exactly morbidity and
mortality rate of this novel procedure, as well as the
real indications are still under investigation [5-21].
Here we report 6 more patients that underwent to
ALPPS procedure; furthermore, a review of the current
English literature is performed in order to have a
general overview of its indications and main outcome.
CASE REPORT
Patient details, surgical procedures and outcomes are
summarized in Table 1. Postoperative complications
were classified using standard Clavien-Dindo
classification [22].
A prophylactic antibiotic was given as a single shot
intraoperatively. The first step was a bilateral subcostal
incision. Exploration was carried out to confirm
absence of extrahepatic dissemination. The round
hepatic, falciform, triangular and coronary ligaments
were dissected and the right liver lobe was mobilized
from the anterior caval vein surface. Intraoperative
ultrasound confirmed lesion localizations and their
relation to major remaining vessels and confirmed their
resectability.
Then, left lobe atypical metastasectomies
were performed in order to obtain a free FLR.
Hepatic-duodenum ligament was dissected and
the hilar plate taken down, thus, hilar structures
(portal vein, common bile duct and common hepatic
artery) were identified and exposed close to their
particular bifurcation in order to perform a future
extended right hepatectomy. Right portal vein was
finally ligated. The right hepatic artery and right bile
duct were marked with vessel loops to facilitate the
future approach to the pedicle elements. At this point
parenchymal transection began between segments II/
III and IV/I using bipolar coagulation and hemo-clips.
Intraoperative ultrasound was performed to confirm the
absence of right portal flow at the end of the first step.
In case 2 (Table 1), at this point a macroscopic
liver congestion and change in color of the FLR were
noted (Figure 1A), as a consequence of a portal
hyper perfusion, confirmed by Doppler ultrasound
(100 cm/sec). A spleno-renal venous shunt was
performed (Figure 1B) to reduce the portal inflow
allowing normalization of previous macroscopic and
ultrasound characteristics (20 cm/sec) of the FLR.
One round, closed abdominal drain was left in place.
Patients were transferred to the Intensive Care Unit
and then discharged according to the postoperative
course. After 7 days, a volumetric CT scan evaluated FLR
hypertrophy in order to plan second stage procedure
(Figure2).Case2showedaFLRhypertrophyofonly30%
after7days;secondstepwasplanneduntilanenoughFLR
according to body weight was reached, which occured

2. 52 Lelpo B, Carusco R, Ferri V, et.al.
Hepato-Gastroenterology 60 (2013)
only after 21 days with a FLR hypertrophy of 56%.
The second stage was performed through the
previous incision site. Surgery was completed
by sectioning the right hepatic artery, right bile
duct and hepatic veins already isolated and
tagged with colored vessel loops. A fibrin-based
sealant was usually left in the liver transection
surface with one round, closed abdominal drain.
In case 3 (Table 1), a longitudinal left supra-hepatic
vein resection was necessary to complete the liver
transection. Venous reconstruction was performed with
prolene 5/0 (Figure 3). In case 4 (cholangiocarcinoma),
a resection of main extrahepatic biliary duct was
performed with a hepatico-jejunostomy. During the
postoperative course, the patient developed a biliary
leak, treated by means of a percutaneous transhepatic
catheter. Case 5 underwent a concomitant right
colectomy for a synchronous right colon tumor
during the first stage. The patient died on the 21st
postoperative day from acute respiratory distress.
The overall mean follow-up was 16.2
months with one case of liver remnant early
recurrence at 4 months after surgery (Table 1).
DISCUSSION
Extended liver resections are frequently necessary
to achieve R0 resections, however, most of the time this
procedure cannot be safely performed because of an
insufficient FLR [1]. One of the first advances in order
to face this issue was introduced by Makuuchi in 1980
and consists of portal vein embolization (PVE) [23].
Since then, PVE continues to be the most
important procedure to induce hypertrophy of
FLR. However, this process, in general takes a mean
time of 4–6 weeks to achieve sufficient growth of
the remnant liver, thus, meanwhile, increasing the
risk for malignancy progression. Furthermore, it
allows an average of only 20% of hypertrophy of
remnant liver volume which may be insufficient for
almost 30% of potentially curative patients [24].
In the last decade various techniques have been
described to improve the result of PVE, such as the “two
stage hepatectomy” however this technique does not
allow any further increase of FLR hypertrophy, mainly
indicated for bilateral liver malignancies [25]. Recently,
this technique has been modified by performing a
portal vein ligation with a “split in liver”, named ALPSS
procedure. In the first stage of this procedure, the liver is
completely divided from the FLRand with a concomitant
portal ligation of the lobe that will be removed [4]. The
FLR is cleaned up by atypical resections of tumors. The
second stage is usually performed 1–2 weeks later.
In this procedure, the deportalized liver is removed.
This novel strategy represents a model of auxiliary
liver for the initial and critical period after extensive
hepatic resection, supplying the metabolic function
until FLR has grown enough. This allows an increase in
hypertrophy (mean of 80%) of the FLR in a brief period
(7–10 days); thus, allowing to perform the second step
earlier. Therefore, ALPPS technique offers a solution
for the two mayor limitations of PVE and “two stage
hepatectomy” (little hypertrophy and long time to
achieve it). The physiopathology of this increased and
rapid hypertrophy relies in the complete disconnection
of intra-hepatic portal vein branches, which can only be
achieved when liver partition is performed. This could
be the reason why after some technically successful
PVE they eventually fail in provide sufficient FLR
hypertrophy. However, the mechanisms that participate
to induce this hypertrophy have yet to be investigated.
The first formal report of this novel approach was
presented by Baumgart in 2011, during the 9th
E-AHPBA
meeting [4]. Since then, considering only the English
literature, a number of cases have been reported in
a very short period of time (2 years), as showed in
Table 1 [5-21]. Now we add 6 more cases of successful
ALPPS procedure to the literature, reporting oncological
outcome, morbidity and mortality rate (Table 1).
In case 2, despite sufficient FLR volume hypertrophy
(56%), the patient developed severe liver failure.
However, after Molecular Adsorbent Recirculating
System (MARS®
) therapy, the patient recovered well and
was discharged with a normal liver function. We think
that the reason for this initial complication was a small-
for-size like syndrome [26]. This disease appears in liver
transplantation whenportalhyperperfusionofthesmall
graft combined with poor venous outflow develops
sinusoidal congestion and liver dysfunction. This
complication is usually challenging, and it is important
to solve it intraoperatively with an immediate detection
(macroscopic liver turgidity, change in color), and solve
it decreasing the portal inflow (porto-systemic shunt)
(Figure 1). Despite these interventions, our patient still
FIGURE 1. Operative field. (A) FRL turgidity and change in color; (B) Spleno-renal venous
shunt.

3. 53
ALPPS: State of the Art Hepato-Gastroenterology 60 (2013)
Patients
Diagnosis
Sex
Age
Neoadjuvancy
Type
of
hepatic
resection
Liver
hypertrophy
(%)
Days
between
I
and
II
step
Type
of
complication
Clavien-
Dindo
classification
Hospital
stay
(days)
Follow-up
1
CRLM
Female
56
yes
Right
+
segm
IV+I
125%
21
None
I
24
27
months,
alive
2
CRLM
Female
59
yes
Right
+
segm
IV+I
56%
15
“Small
for
size”(ISGLS
grade
C)
*
IVA
60
30
months,
alive
3
CRLM
Female
63
yes
Right
+
segm
IV
+
LSV
resection
214%
12
None
I
28
16
months
(alive
with
recurrence
at
4
months)
4
CC
Female
62
no
Right
+
segm
IV
110%
13
Biliary
leak
IVA
36
6
months
5
CRLM
Male
57
yes
Right
+
segm
IV
+
right
colectomy
81%
15
ARDS
V
21
death
at
21
days
6
CRLM
Male
58
yes
Right
+
segm
IV
76%
16
None
I
23
2
months,
alive
CRLM:
Colorectal
liver
metastases;
CC:
Cholangiocarcinomas;
ARDS:
Acute
respiratory
distress
syndrome:
LSV:
Left
suprahepatic
vein
*
:
Post
Hepatectomy
Liver
Failure
grade
C
[23].
TABLE
1.
Main
patient
characteristics
and
outcome.
developed severe liver insufficiency, even if 56% of FLR
hypertrophy was enough according to her body weight.
However, with this data we render this complication
not as a true liver insufficiency, but must likely a
postoperativeliverfailure,duetoahyperperfusionofFLR.
Once completed the first ALPPS stage, should we
perform routinely a Doppler portal flow measurement
and decrease it when too high, to reduce potentially
postoperative “small for size “alike syndrome? Further
studies are needed to confirm this hypothesis. We
performed a research on English literature through
PubMed in order to have an overview about main
outcome of ALPPS procedure. Up to date we found 18
papers (Table 2). To begin with, this review shows that
most of the important perioperative and postoperative
data are lacking; however, it allows us to have an
overview concerning the state of the art of ALPPS.
According to this, including also our series, it seems to
take almost 11 days to achieve sufficient growth of the
FLR with a mean hypertrophy of 84% [4-21]. Apparently,
the ALPPS procedure is a potentially effective technique
for massive liver malignancies. However, according to
this review, morbidity and mortality rates reported are
higher than conventional standardized techniques. We
see that the mean morbidity rate recorded resulted to
be almost 35% with the most frequent complication
represented by biliary leak (20%). Surgeons should
always be aware of this complication. In our opinion,
from a technical point of view, the collocation of an
intracystic drainage after liver splittering may reduce
the intrahepatic biliary tension, thus, reducing biliary
leakage from resected liver parenchyma. The higher
incidence of biliary leak was found in the series which
include cholangiocarcinoma and when main biliary
duct resection was performed. Furthermore, the
author performed routinely a right bile duct ligation
to further enhance FLR volume. However, he stated
that the high biliary fistula and biloma incidence
reported (87.5%) may be explained by the main
duct ligation, thus, recommending it not be routinely
performed. Our experience confirms this hypothesis
as our case of biliary leak was in case 4 where a
resection of main biliary duct was performed [14].
Furthermore, it has been reported that patients
undergoing ALPPS for hilar cholangiocarcinoma
have an additional risk for intra-abdominal infection
and bacteraemia after hepatectomy [9], due to
preoperative biliary manipulation. Despite the huge
FLR hypertrophy, mean postoperative liver failure
reported, according to ISGLS classification [27]
is 28%, consistent with our experience (16.6%).
However, most of the time, grade of liver failure is
not reported by the authors. Mean postoperative
mortality rate, according to this review, range from
0 to 22%. Mortality rate of our case series is 16.6%.
Considering all previous data, it is important to
take into account all these potentially postoperative
complications whenever ALPPS procedure is planned.
With regards to oncological outcome, this review
shows also a lack of long-term follow-up; only 5 out
of 18 series presented this data (Table 2). We must
underline that this is important in order to define the
indication of this technique. The increased acceleration
of FLR growth may logically increase the proliferative
activity of intrahepatic micro-metastases in patients
with liver involvement. Surgeons must carefully reflect
on this point; we suggest performing a PET scan and,
in selected cases, a laparoscopic ultrasound before
undergoing this procedure. Sala et al. [15] reported a
20% of liver remnant recurrence rate at only 187 days
of follow-up, similar to our experience (16.6%) (Table
2). However, further data on long-term follow-up will
help us to understand the implications of this point.
ItisalsoimportanttounderlinethatALPPSprocedure

4. 54 Lelpo B, Carusco R, Ferri V, et.al.
Hepato-Gastroenterology 60 (2013)
Patient
(n)
Liver
Disease
Neoadyuvancy
Days
Between
I
and
II
Step
(Mean,
Range)
Hypertrophy
Type
Of
Resection
Mortality
Morbidity
PHLF
Follow
Up
(mean
months)
DFS
(%)
present
study
5
4MTS
1CC
4
16
(12-21)
131%
3ERH
1ERH
+
colectomy
1ERH
+
main
duct
resection
20%
60%
(20%
BL)
20%grade
C
17.7
80%DFS
Gauzolino
2013
4
4MTS
4
7
40.4%
Classical
Left
Recue
Right
0
75%
(10.2%
BL)
0
4
0%
DFS
Torres
2013
39
32MTS
3CC
2
Sarcoma
1
cyst
1HCC
na
14.1
(5-30)
83%
na
12.8%
59%
2.5%
na
Alvarez
2013
15
13MTS
1HCC
1CC
10
7
78.4%
RH/RHE/LHE
0
53%
(20%
BL)
10%grade
A
10%grade
B
6.2
73%
DFS
Machado
2013
1
MTS
na
21
na
Laparoscopic
ERH
+
WR
seg
II
0
0
0
na
Knoefel
2013
7
Na
6
6
(4-8)
63%
ERH
9
%
27%
(18%
BL
9%
AL
)
na
na
Li
2013
9
(3
*
previus
reported)
3
MTS
6
CC
3
13
(9-16)
87.2
%
ERH
22%
22%
BL
11%grade
A
11%grade
C
na
Donati
2013
8
na
na
na
66-200%
na
na
na
na
na
TABLE
2:
Literature
review
including
our
cases
report.

5. 55
ALPPS: State of the Art Hepato-Gastroenterology 60 (2013)
Cavaness
2012
1
HCC
0
4
100%
ERH+
left
portal
vein
resection
0
0
100%
grade
A
na
Andriani
2012
2
MTS
na
30
na
ERH
0
0
0
30,
48
100%
DFS
Conrad
2012
1
MTS
1
9
72%
Laparoscopic
RH+
seg
I
0
0
100%
grade
A
na
Machado
2012
1
MTS
na
9
88%
Laparoscopic
ERH
+
WR
seg
III
0
0
0
na
Dokmak
2012
8
na
na
7
70%
4
ERH
4
Whipple
+
main
duct
resection
13%
87
%
BL
26%grade
C
na
Sala
2012
10
na
na
7
82%
4
RH
5
ERH
1
ELH
0
40%
20%
grade
A
11
80%
DFS
Govil
2012
1
na
na
na
na
RH
na
na
na
na
Schitzbauer
2012
25
3
HCC
4CC
1
HE
1GC
16
MTS
12
9
(5-28)
74%
ERH
40%
biliary
recostruction
20%
64%
(20%
BL
8%
AL
)
na
80%
DFS
8%
died
for
recurrent
disease
Santibañes
2012
3
2
MTS
1
CC
2
7
40-
80%
2
RH
1
ERH
0
33%
BL
0
na
Oldhafer
2012
1
MTS
na
28
90%
ERH
+
WR
seg
III
0
0
na
na
Baugmart
*
2011
3
na
na
7
62%,
75%,
80%
ERH
na
na
na
na
Total
142
11.6
84.19%
6%
35%
*patients
included
in
“Schitzbauer
el
al”;
na:
not
available;
HCC
hepatocellular
carcinoma;
CC
cholangio
carcinoma;
HE
hemangioendothelioma;
GC
gallbladder
cancer;
MTS
metastasic
disease;
KT
Klatskin
tumor;
RH
right
hepa-
tectomy;
ERH
extended
right
hepatectomy
(RH
+
SEG
I
and
IV);
LH
left
hepatectomy;
ELH
extended
left
hepatectomy;
WR
wedge
resection;
PVL
portal
vein
ligation;
BL
biliar
leak;
AL
anasthomotic
leakage;
DFS
disease
free
survival;
PHLF
post
hepatic
liver
failure
(ISGLS
classification).
TABLE
2:
Literature
review
including
our
cases
report.
(CONT)

6. 56 Lelpo B, Carusco R, Ferri V, et.al.
Hepato-Gastroenterology 60 (2013)
does not replace PVE, which should remain the gold
standard procedure for mono-lobar liver malignancies.
Indeed, as reported recently by Shindoh et al., PVE
for monolobal liver malignancies remains the gold
standard for patients with very low FLR volumes [28].
ALPPS procedure should be considered only when
bilateral multiple malignancies are present in the liver,
where the FLR volume, calculated in the preoperative
work out, is not adequate or finally, in an unexpected
intraoperative scenario when we find the previous
mentioned conditions. We would like to stress the
concept that this new procedure should be taken
into account whenever a liver extended resection
has to be performed. Despite recent progress in
imaging techniques, intraoperative liver ultrasound is
responsible for a change in operative strategy in almost
16% of patients, because of earlier detection of lesions
[29].Inthiscase,ALPPShastobeconsideredimmediately
as an alternative efficacy tool to achieve resectability.
However, given the reported ALPPS associated
complications, further studies are needed to understand
which patients are the best candidates to this procedure.
Amorepreciseindicationofthisinnovativeprocedure
may be after failed PVE with insufficient growth of
the FLR, in a context of extensive liver malignancy.
When an extensive hepatic resection is planned for
metastatic disease, simultaneous resection of primary
colorectal cancer is usually delayed for a second
surgery. An important advantage of ALPPS technique
is that it reduces the extended hepatectomy into two
less aggressive surgeries allowing the resection of the
primary colorectal cancer simultaneously in the first
or second stage. In our series, case 5 was associated
to right hemicolectomy during the first stage; however,
this patient died for respiratory distress syndrome.
Important adhesions in the second stage, even after
only a few days from the first stage procedure, are
frequently described with this technique producing
difficulties during surgery. These adhesions may be
due to the biliary leakage, which could be prevented
with a plastic bag or biological tissue, as suggested by
some authors [9]. However, as referred by Schnitzbauer
[17], wrapping the whole right lobe with a plastic bag
is not recommended because of the possible formation
of not adequately drained fluid collections. Some
authors describe the first stage of ALPSS procedure
using a laparoscopic approach in order to prevent and
reduce adhesions during the second stage [6,7,13].
In literature various modifications of the technique
has been reported. In a Spanish language article, Robles
et al. [30], suggests an alternative way to disconnect
the intra-hepatic flow during the first step by applying
a tourniquet to the future line of transection, using the
hanging maneuvers, thus, reducing potentially the first
step operative time and complications. However, further
studies are needed to confirm these preliminary results.
Gauzolinoetal.[20]describesthreemodificationofthe
classicaltechniquenamed“leftALPPS”:ligationoftheleft
portal vein, “rescue ALPPS” after a failed PVE and finally
a “right ALPPS”, consisting in ligation of postero-lateral
branch of right portal vein, left lateral sectionectomy,
multiple resections on the right anterior and left medial
section and splitting along the right portal fissure.
An international registry and a multicenter
randomized study on ALPPS procedures is in progress
anditwillofcoursehelpustobetterunderstanditsimpact
on liver surgery and may define those patients who can
benefit from this innovative and promising procedure.
Conclusions
Our initial experience and literature review shows
the efficacy of ALPPS procedure to induce a huge FLR
hypertrophy, but at the price of a higher morbidity
and mortality. Remnant issues are the real indications
of this novel technique and its oncological outcome.
ACKNOWLEDGMENTS
The authors thank Isabel de Sala and Pablo Ruiz for
their collaboration.
FIGURE 3. Supra-hepatic left venous reconstruction.
FIGURE 2. Postoperative CT scan. (A) Abdominal CT scan; (B) Volu-
metric CT scan.

7. 57
ALPPS: State of the Art Hepato-Gastroenterology 60 (2013)
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