Overview
Definition:
Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a surgical technique designed to induce rapid hypertrophy of the future liver remnant (FLR) in patients with insufficient liver volume for a safe major hepatectomy
It involves dividing the liver parenchyma in the planned plane of resection and ligating the portal vein to the side to be removed, thereby shunting blood flow to the contralateral lobe
This process promotes compensatory hypertrophy of the FLR, allowing for a subsequent two-stage resection of extensive liver malignancies or bilobar disease.
Epidemiology:
ALPPS is a relatively recent innovation, first described in 2007
Its application has expanded significantly, particularly in centers specializing in complex liver resections
It is primarily indicated in patients with otherwise unresectable liver tumors due to insufficient FLR, often associated with colorectal liver metastases, hepatocellular carcinoma, or cholangiocarcinoma, and in cases of benign liver tumors requiring extensive resection
The incidence is thus tied to the prevalence of these liver malignancies and the need for aggressive surgical management.
Clinical Significance:
ALPPS addresses a critical challenge in liver surgery: achieving adequate FLR hypertrophy before undertaking a second-stage resection when standard techniques like portal vein embolization (PVE) are insufficient or too slow
It allows potentially curative resections in patients who would otherwise be deemed inoperable due to limited liver reserve
This technique has expanded the oncological resection window for liver tumors, offering hope for improved survival and quality of life
Its understanding is crucial for surgeons, oncologists, and hepatologists involved in managing complex liver pathologies and preparing for DNB/NEET SS surgical examinations.
Indications
Absolute Indications:
Inoperable liver tumors due to insufficient FLR volume (FLR volume < 20% in normal liver, < 30% in cirrhotic liver)
Bilobar disease requiring staged resection
Primary liver tumors with extensive involvement
Post-chemotherapy liver disease requiring major resection
Unresectable colorectal liver metastases with insufficient FLR.
Relative Indications:
Rapidly progressive liver disease
Need for rapid tumor debulking
Patients with pre-existing liver dysfunction where standard PVE is less effective
Large primary tumors requiring more than three segments resection
Patients undergoing neoadjuvant chemotherapy where response is suboptimal or progression occurs.
Contraindications:
Uncontrolled sepsis
Severe coagulopathy
Extensive extrahepatic disease
Unacceptable comorbidity burden
Significant tumor involvement of the major hepatic veins or vena cava
Inability to tolerate two-stage surgery
Advanced liver cirrhosis (Child-Pugh C) not amenable to ALPPS.
Patient Selection:
Careful multidisciplinary assessment is vital
Imaging (CT, MRI) for tumor burden, FLR volume assessment, and vascular involvement
Liver function tests (AST, ALT, Bilirubin, Albumin, INR)
Assessment of comorbidities
Patient performance status (ECOG/KPS).
Procedure Steps
Inflow Occlusion And Parenchymal Division:
Stage 1: Laparotomy or laparoscopy
Intrahepatic division of the liver parenchyma in the planned resection plane, typically along the falciform ligament for right-sided resections
Careful identification and preservation of the hepatic veins draining the FLR
Ligation of the portal vein branch supplying the segment(s) to be resected
Placement of drains and closure.
Preoperative Interval:
Post-Stage 1, the patient is closely monitored
The interval is typically 7-14 days
Serial imaging (CT scan) is performed to assess FLR hypertrophy
Liver function tests and inflammatory markers are monitored
Nutritional support is optimized.
Second Stage Hepatectomy:
Stage 2: Performed after adequate FLR hypertrophy is confirmed
Re-laparotomy or completion laparoscopy
The previously divided parenchymal plane is revisited
Dissection of the tumor-bearing segments
Ligation and division of hepatic artery and bile duct supply to the resected segments
Mobilization and division of the resected liver mass
Management of hepatic veins draining the FLR
Hemostasis and biliary reconstruction as needed
Placement of drains and closure.
Technique Variations:
In-situ split (most common)
Ex-situ technique (rarely used)
Different approaches to vascular control and parenchymal division
Use of intraoperative ultrasound to delineate resection margins.
Postoperative Care
Immediate Postoperative Period:
Close monitoring in ICU
Hemodynamic stability, fluid balance, electrolyte correction
Pain management
Strict fluid restriction
Monitoring of urine output
Prophylaxis against deep vein thrombosis and stress ulcers.
Monitoring For Complications:
Close observation for signs of post-hepatectomy liver failure (PHLF), sepsis, bile leak, intra-abdominal bleeding, and hepatic vein thrombosis
Serial monitoring of liver function tests (bilirubin, INR, albumin), inflammatory markers (CRP, WBC), and coagulopathy.
Nutritional Support:
Early initiation of enteral nutrition if tolerated, otherwise parenteral nutrition
High protein, calorie-rich diet
Management of ascites and fluid overload.
Discharge Criteria:
Stable vital signs
Tolerating oral intake
Adequate pain control
No signs of PHLF or other major complications
Mobilization and independent ambulation
Satisfactory laboratory parameters.
Complications
Post Hepatectomy Liver Failure Phlf:
The most feared complication, characterized by coagulopathy (INR < 4.0 by day 5) and encephalopathy (grade III-IV)
Often managed conservatively with supportive care, plasma, vitamin K, and in severe cases, liver transplantation.
Sepsis And Infection:
Intra-abdominal abscess, biliary tract infection (cholangitis), and systemic sepsis
Prompt diagnosis and aggressive management with antibiotics and drainage are crucial.
Bile Leak:
Leakage of bile from hepatico-jejunal anastomosis or cut hepatic ducts
Managed with drainage, endoscopic retrograde cholangiopancreatography (ERCP) with stenting, or re-operation.
Bleeding:
Postoperative hemorrhage from surgical site or within the liver parenchyma
May require blood transfusions, re-exploration, or interventional radiology embolization.
Hepatic Vein Thrombosis:
Occlusion of hepatic veins draining the FLR, leading to congestion and potential liver failure
Management may involve anticoagulation or thrombolysis.
Embolism:
Pulmonary embolism is a risk
Prophylaxis with anticoagulants and early ambulation is essential.
Prognosis
Factors Affecting Prognosis:
Extent of liver resection
Underlying liver histology (cirrhosis vs
normal parenchyma)
Tumor type and stage
Preoperative liver function
Development of postoperative complications, especially PHLF and sepsis
Surgical expertise and center volume.
Outcomes:
ALPPS has enabled curative resections in patients previously deemed inoperable, leading to improved survival rates for certain liver malignancies
However, it is associated with higher morbidity and mortality compared to standard hepatectomy due to the aggressive nature of the procedure and the compromised liver reserve in many patients
Short-term outcomes are often challenging, with significant rates of PHLF and sepsis
Long-term oncological outcomes are encouraging when a complete R0 resection is achieved.
Follow Up:
Postoperative follow-up includes serial imaging to monitor for tumor recurrence and assess liver regeneration
Regular clinical examinations and laboratory tests to monitor liver function and general health
Adjuvant therapy may be considered based on tumor type and stage
Long-term surveillance protocols are essential for timely detection of recurrence.
Key Points
Exam Focus:
ALPPS is a staged hepatectomy technique to enable resection in patients with insufficient FLR
It involves two stages: parenchymal division and portal vein ligation (Stage 1), followed by resection of the ischemic liver lobe (Stage 2)
Rapid hypertrophy of FLR is the key principle
Complications like PHLF and sepsis are significant
Patient selection and multidisciplinary management are paramount
Understand the indications and contraindications thoroughly.
Clinical Pearls:
Accurate FLR volumetry is crucial for patient selection
Consider the timing of Stage 2 based on hypertrophy response and patient clinical status
Aggressive management of complications is vital
Multidisciplinary tumor board discussions are essential
Documenting pre- and post-operative liver function and hypertrophy is key for evaluating outcomes.
Common Mistakes:
Incorrect patient selection (e.g., inadequate FLR, excessive comorbidities)
Underestimating the risk of PHLF and sepsis
Delaying Stage 2 unnecessarily or performing it too early
Inadequate monitoring of FLR hypertrophy
Insufficient postoperative care and management of complications
Lack of a multidisciplinary approach.