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

Abstract

The main obstacle to achieving an R0 resection after a major hepatectomy is inability to preserve an adequate future liver remnant (FLR) to avoid postoperative liver failure (PLF). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel technique for resecting tumors that were previously considered unresectable, and this technique results in a vast increase in the volume of the FLR in a short period of time. However, this technique continues to provoke heated debate because of its high mortality and morbidity.The evolution of ALPPS and its advantages and disadvantages have been systematically reviewed and evaluated in accordance with current evidence. Electronic databases (PubMed and Medline) were searched for potentially relevant articles from January 2007 to January 2016.ALPPS has evolved into various modified forms. Some of these modified techniques have reduced the difficulty of the procedure and enhanced its safety. Current evidence indicates that the advantages of ALPPS are rapid hypertrophy of the FLR, the feasibility of the procedure, and a higher rate of R0 resection in comparison to other techniques. However, ALPPS is associated with worse major complications, more deaths, and early tumor recurrence.Hepatobiliary surgeons should carefully consider whether to perform ALPPS. Some modified forms of ALPPS have reduced the mortality and morbidity of the procedure, but they cannot be recommended over the original procedure currently. Portal vein embolization (PVE) is still the procedure of choice for patients with a tumor-free FLR, and ALPPS could be used as a salvage procedure when PVE fails. More persuasive evidence needs to be assembled to determine whether ALPPS or two-stage hepatectomy (TSH) is better for patients with a tumor involving the FLR. Evidence with regard to long-term oncological outcomes is still limited. More meticulous comparative studies and studies of the 5-year survival rate of ALPPS could ultimately help to determine the usefulness of ALPPS. Indications and patient selection for the procedure need to be determined.

Figure 1

ALPPS and modified ALPPS (green: line for resection and splitting of the liver; gray: Ligature thread). A, Conventional ALPPS: first surgery: right PVL and in situ splitting of the liver parenchyma (with or without local resection). Second surgery: hepatectomy. B, ALTPS: first surgery: right PVL and placement of a tourniquet on the umbilical ligament, instead of in situ splitting of the liver parenchyma (with or without local resection). Second surgery: hepatectomy. C, Hybrid ALPPS: first surgery: in situ splitting of the liver parenchyma via an “anterior approach” (with or without local resection) and right PVE one day later. Second surgery: hepatectomy. D, p-ALPPS: first surgery: right PVL and partial partition to the level of the middle hepatic vein (with or without local resection). Second surgery: hepatectomy.