Modif i cations of ALPPS - from complex to more complex or from complex to less complex operations

Wan Yee Lau and Eric CH Lai

Hong Kong, China

Modif i cations of ALPPS - from complex to more complex or from complex to less complex operations

Wan Yee Lau and Eric CH Lai

Hong Kong, China

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 insuff i cient 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 modif ications of the conventional ALPPS procedure.

DATA SOURCES:Studies were identif i ed 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 identif i ed by a manual search of references from key articles.

RESULTS:There have been a lot of modif i cations of the conventional ALPPS. These are classif i ed as: (1) modif i cations aiming to improve surgical results; (2) modif i cations aiming to expand surgical indications; (3) salvage ALPPS; (4) ALPPS using the minimally invasive approach. Some of these modifi cations 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 modi fi cations have been reported in small case series or case reports. We need better well-designed studies to establish the true roles of these modi fi cations. 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 modif i cations have expanded the use of ALPPS in patients who have been considered to have unresectable liver tumors. The long-term oncological outcomes of these modif i cations are still unknown.

(Hepatobiliary Pancreat Dis Int 2017;16:346-352)

associating liver partition and portal vein ligation for staged hepatectomy; hepatocellular carcinoma; hepatectomy; liver metastasis; portal vein embolization

Introduction

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a new strategy which has been developed to induce accelerated hypertrophy of future liver remnant (FLR) in order to increase resectability of liver tumors and reduce the risk of postoperative liver failure. Since its introduction, many surgeons around the world have rapidly adopted ALPPS as it has the advantages of inducing rapid liver hypertrophy of 47% to 100% over a median of 6 to 16 days, and 95% to 100% completion of tumor resection rate for the 2-staged operation.[1-20]Even in patients with chronic liver diseases, severe steatosis, liver fi brosis or cirrhosis, liver hypertrophy rates, although less predictable, have been reported to vary from 18.7% to 100% over a median of 7 days.[21-27]The main criticisms of ALPPS are its high morbidity and mortality rates. The morbidity rates after ALPPS have been reported to be 15.3% to 100% with ≥Clavien-Dindo Grade II being 13.6% to 44%, and the reported mortality rates ranged from 0 to 29%.[1-20]Thus ALPPS is not accepted by some surgeons who believe portal vein embolization or portal vein ligation to be much safer than ALPPS. Because of the longer timeinterval to wait for the FLR to hypertrophy adequately, the risk of drop out from completion of tumor resection is signif i cantly lower in ALPPS, due to either tumor progression or insuff i cient hypertrophy of FLR.[28-32]

Since the introduction of the conventional ALPPS, surgeons have reported on various modif i cations of the procedure, aiming to decrease the perioperative morbidity and mortality rates, to improve postoperative longterm survival and to improve the completion of tumor resection of the ALPPS phase 2 operation. This article aimed to review the technical modif i cations of the conventional ALPPS procedure.

Methods

Studies were identif i ed 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 identif i ed by a manual search of references from key articles. All articles on technical modif i cations of ALPPS were included in this review.

Results

Conventional ALPPS and its initial development

Professor Hans Schlitt from Regensburg, Germany fi rst carried out this operation in 2007. He originally planned to carry out an extended right hepatectomy for a patient with hilar cholangiocarcinoma. During the operation, he found the FLR to be too small for the patient’s survival after surgery. He then decided to carry out a biliary bypass. For optimal exposure and positioning of a jejunal loop for the left hepaticojejunostomy, he carried out anin situsplit of the liver parenchyma on the right side of the falciform ligament. To induce liver hypertrophy of the liver segments 2 and 3, he ligated the right portal vein. Out of curiosity, he performed computed tomography (CT) on postoperative day 9 and found the left lateral section of the liver had adequately hypertrophied. He then carried out the originally planned extended right hepatectomy as a second staged operation. The patient recovered well from the operation. This novel approach was formally presented as a poster presentation on 3 such cases in the 9th European-African Hepato-Pancreato-Biliary Association Congress in Cape Town, South Africa, in 2011 by Dr. Hauke Lang from Mazin, Germany.[33]In the same year, de Santibañes and his colleagues from Argentina adopted this technique and reported their initial experiences on 3 patients.[34]Schlitt and his colleagues reported the technique which they called “right portal vein ligation combined within situsplitting” on 25 patients.[1]Reports started to come from regions around the world with overwhelming enthusiasm. In 2012, de Santibañes and Clavien proposed the acronym for this procedure as associating liver partition and portal vein ligation for staged hepatectomy, or ALPPS in short.[35]Fig. 1 shows the diagrammatic representation of the conventional ALPPS procedure.

Modif i cations of the conventional ALPPS

Although ALPPS is still considered by many surgeons to be in an early developmental phase, and its indications and contraindications have not been well-def i ned, many technical modif i cations of the conventional ALPPS have been successfully carried out and reported. Unfortunately, almost all these reports are case reports or small case series which limit meaningful statistical comparison on treatment outcomes. Validation of success of these techniques are still lacking. Technical standardization of some of these modif i cations is needed before the effectiveness and safety of these modif i cations can be clarif i ed. However, it is interesting to review the gradual changes in the technical modif i cations of the conventional ALPPS and the reasoning behind the modif i cations — a change from complex to more complex, and subsequently from complex to less complex operations using minimally invasive approaches.

Fig. 1. Conventional ALPPS.

Modif i cations aiming to improve surgical results

The initial aims of introducing modif i cations to the conventional ALPPS were to decrease perioperative morbidity and mortality rates, improve long-term survival, and improve the completion tumor resection rate of the phase II ALPPS. There is still a lack of consensus of adopting the following modif i cations because these modif i cations can result in a more complex operation and some of these modif i cations fail to achieve what they have been designed to achieve. Sometimes, they can even result in worse outcomes. These modif i cations include：

(i) Time interval between the 1st and 2nd phases of ALPPS to extend to be more than 14 days. The main reason is because of inadequate liver hypertrophy of the FLR within the second week after the 1st phase of ALPPS.[36]

(ii) As bile leakage after the 1st phase of ALPPS led to signif i cant morbidity and mortality rates due to sepsis, a plastic bag was introduced to wrap around the liver after liver transection and drains were placed into the plastic bag to drain any body fl uid or bile to outside of the body.[1]However, there are two disadvantages of using a plastic bag. First this is a foreign body which can lead to sepsis. Second, even if a 2nd phase ALPPS cannot be done due to inadequate liver hypertrophy, a second operation still needs to be carried out to remove the plastic bag. As a consequence, the use of bags made of absorbable material or the use of biologic sealant have been proposed.[37,38]

(iii) As the arterial and portal blood supply to liver segment 4 is compromised by liver transection along the right side of the falciform ligament, Andriani and his associates proposed to resect this liver segment in an attempt to decrease any ischemia to liver segment 4 which may become infected.[39]This segment 4 resection is now seldom done as it adds to the complexity without providing any obvious advantage to the surgery.

(iv) Simultaneous ligation of the right hepatic artery, aiming to increase the liver hypertrophy rate.[40]Again this is now seldom carried out as this adds to the complexity without any obvious advantage to the surgery.

(v) To preserve the middle hepatic vein in the left liver aiming to improve venous drainage of the liver segment 4 which may decrease the risk of necrosis and bile leakage.[12]This should be done if technically possible.

(vi) To use the anterior approach with or without the liver hanging technique. The aim is to decrease adhesions formation after the 1st phase of ALPPS. In patients with a large tumor in the right liver, this approach can decrease the chance of tumor rupture during liver mobilization.[17,41]

(vii) The “no touch technique” aiming to improve the long-term results of ALPPS.[42]

Modif i cations aiming to expand surgical indications of the conventional ALPPS by preserving different liver segments

All these modif i cations of the conventional ALPPS increase the technical diff i culty of the operation. However, these modif i cations were designed for patients with liver tumors that were considered to be unresectable even with the conventional ALPPS. There are still not enough data to support whether the long-term results justify the increased risk of these procedures.

(i) To preserve the right liver (liver segments 5, 6, 7, 8)[42](Fig. 2)

(ii) To preserve liver segments 4, 5, 8[36](Fig. 3)

(iii) To preserve the left liver (liver segments 2, 3, 4)[36](Fig. 4)

Fig. 2. Modif i cation to preserve right liver (i.e. segments 5, 6, 7, 8).

Fig. 3. Modif i cation to preserve liver segments 4, 5, 8.

This is used in patients with a huge liver tumor (＞10 cm) in the right liver and the size of the FLR in the left liver is too small. This modif i cation will hopefully resultin adequate liver hypertrophy in the FLR within 1 to 2 weeks. If portal vein embolization or portal vein ligation is to be used, the wait needs to be 4 to 6 weeks before resectional surgery can be carried out. By then the tumor may have progressed to become unresectable.

(iv) Doublein situliver split for staged mesohepatectomy (Fig. 5)

This is used in patients with gallbladder cancer.[43]The operation requires resection of liver segments 1, 4, 5, 8 with preservation of liver segments 2, 3, and 6, 7. Right and left hepaticojejunostomy and regional lymphadenectomy form parts of the operation.

(v) Monosegment ALPPS

The operation includes resection of all liver segments but leaving behind：[44-46]

·Segment 2+1/2 segment 4

·Segment 3+segment 1

·Segment 4+segment 1 or (+) 1/4 segment 2

·Segment 6+segment 1

Salvage ALPPS[47,48]

Fig. 4. Modif i cation to preserve left liver (i.e. liver segments 2, 3, 4).

Fig. 5. Doublein situsplit for staged mesohepatectomy. IVC： inferior vena cava.

Sometimes, either a right or left portal vein embolization results in inadequate liver hypertrophy in the FLR. Salvage ALPPS is carried out by parenchymal transection along the mid plane of the liver between the right and the left liver. The 2nd phase ALPPS can be carried out when the FLR has hypertrophied to an adequate size by carrying out a right or a left hepatectomy.

ALPPS using the minimally invasive approach

The main aim of using the minimally invasive approach in ALPPS is to reduce surgical trauma. However, using minimally invasive procedures in ALPPS can become technically more diff i cult. Whether the reduced surgical trauma in the minimally invasive procedures can result in better overall surgical outcomes is still unknown.

ALPPS involves 2 phases of a staged operation. For these two operations the approaches can vary from： open surgery, to hand-assisted laparoscopic, to totally laparoscopic, to robotic, and then to percutaneous interventional procedures.

The fi rst phase of ALPPS involves 2 major components：

[A] Liver partition — this can vary from open liver parenchymal transection, to laparotomy+liver tourniquet, to open radiofrequency/microwave for liver parenchymal partition, to laparoscopic liver transection, to laparoscopic liver tourniquet, to laparoscopic radiofrequency/microwave for liver parenchymal partition, and to percutaneous radiofrequency/microwave for liver parenchymal partition.

[B] For blockage of a portal vein branch, it can vary from open portal vein ligation, to laparoscopic portal vein ligation, to percutaneous portal vein embolization.

The second phase of ALPPS involves liver resection which can vary from open, to laparoscopic, to robotic liver resection.

The development of the modif i cations of ALPPS using the minimally invasive approach, involves the various combinations of the above mentioned procedures.

The development can be divided into 3 stages (Table).

(i) Phase 1 of ALPPS uses minimally invasive surgery Phase 2 of ALPPS uses open liver resection

(ii) Phase 1 of ALPPS uses minimally invasive procedures Phase 2 of ALPPS uses laparoscopic or robotic liver resection

(iii) Phases 1 of ALPPS uses percutaneous procedures Phase 2 of ALPPS uses open liver resection

The study by Hong et al[62]using totally percutaneous procedures in the fi rst phase of ALPPS is interesting. The main merits are (i) the percutaneous procedures decrease harm on patients who otherwise have to undergo two major surgical procedures within a time interval of 1 to 2 weeks; and (ii) this 1st phase of ALPPS can be used as a screening procedure to screen out patients who donot have good degree of liver hypertrophy after the 1st phase of ALPPS. The success of this operation is based on the following two observed facts which have been previously reported：

Table. Modif i cations of ALPPS using minimally invasive procedures

(i) There is no difference between the degree of liver hypertrophy in the FLR in partial and complete partition using radiofrequency ablation/microwave[18,63-66]

(ii) After liver partition, percutaneous portal vein embolization can give a similar degree of liver hypertrophy as intraoperative portal vein ligation.[49,62,67]The major precaution that should be taken is the chance of damaging the blood supply to liver segments 2 and 3 if there is too excessive ablation using radiofrequency ablation or microwave on the right side of the falciform ligament, as the blood supply of the left liver (segments 2, 3, 4) goes along the umbilical fi ssure to supply segment 4 on the right side and segments 2, 3 on the left side.

Conclusions

There have been a lot of modif i cations of the conventional ALPPS. Some of these modif i cations made the conventional ALPPS even more complex, although other attempts to make the procedure less complex.

The results of most of these modif i cations have been reported in small case series or case reports. We need well-designed studies to establish the true roles of these modif i cations.

Contributors: LWY proposed the study. Both authors contributed to the design and interpretation of the study and to further drafts. LWY is the guarantor.

Funding: None.

Ethical approval: Not needed.

Competing interest: No benef i ts in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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March 22, 2017

Accepted after revision May 12, 2017

Author Aff i liations: Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China (Lau WY and Lai ECH); Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China (Lai ECH)

Professor Wan Yee Lau, MD, FRCS, FACS, FRACS (Hon), Professor of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China (Tel： +852-2632-2626; Fax： +852-2632-5459; Email： josephlau@cuhk.edu.hk)

© 2017, Hepatobiliary Pancreat Dis Int. All rights reserved.

10.1016/S1499-3872(17)60034-1

Published online June 30, 2017.