The ALPPS technique for bilateral colorectal metastases: three “variations on a theme”

Abstract

The aim of this study was to assess feasibility of technical variations of the associating liver partition and portal vein ligation for staged hepatectomy technique (ALPPS) with regard to three different ways of liver splitting. The ALPPS technique was applied in the classic form consisting in ligation of the right portal vein, limited resections on the left lobe and splitting along the umbilical fissure; the right lobe was removed 1 week later. The first variation was "left ALPPS": ligation of the left portal vein, multiple resections on the right hemiliver and splitting along the main portal fissure. The second variation was "rescue ALPPS", consisting in simple splitting of the liver along the main portal fissure several months after a radiological portal vein embolization that did not allow satisfactory liver hypertrophy. The third variation was "right ALPPS", consisting in ligation of the posterolateral 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. In all cases auxiliary deportalized liver was removed 1 week later. 4 patients with colorectal metastases were included. Morbidity was defined according to the Clavien-Dindo classification: grade I (2 events), grade IIIb (1 event). Postoperative mortality was nil. Median follow-up was 4 months and to date all patients are still alive. ALPPS technique, in its "classical" and modified forms, is a good option for selected patients with bilateral colorectal metastases and represents a feasible alternative to classical two-stage hepatectomy.

An updated systematic review of the evolution of ALPPS and evaluation of its advantages and disadvantages in accordance with current evidence

“…In 2013, Gauzolino et al [53] described 3 modified forms of the original ALPPS procedure. Four patients were enrolled in their study: 1 underwent the original ALPPS procedure, 1 underwent left ALPPS, 1 underwent rescue ALPPS, and 1 underwent right ALPSS.…”

Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases?

“…Indeed, since its initial description, there have been refinements in patient selection as well as operative technique that potentially will result in a decreased morbidity and mortality associated with the procedure. [26][27][28] As is the case with many new techniques, we hypothesize that there will be an inherent learning curve and that much lesser rates morbidity and mortality will be observed with further improvements on the technique. In our experience, we suggest that preservation of the middle hepatic vein, complete transection of the liver parenchyma, and minimal dissection of the hepatoduodenal ligament will minimize the risk of biliary or arterial complications and prevent complete devascularisation of segment 4.…”

Portal Vein Embolization versus Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy

“…In fact, various refinements to the ALPPS procedure are being reported to improve on the morbidity and mortality rates. These changes include using different approaches of in situ liver splitting (tourniquet compression [17] and radiofrequency ablation [18]), differing extent of liver transection (partial ALPPS [19]), and selecting different planes of liver splitting (right and left ALLPS [20], monosegment ALPPS [21]).…”