'In-Situ Split' Liver Resection/ALPPS - Historical Development and Current Practice

Abstract

Background: Liver tumors that are extensive, multifocal, or critically located frequently require advanced techniques of liver resection including '!' - enabling liver resection in certain situations.

Methods: The development of the technique in the first and the subsequent 8 patients in the index center, and also the method's spread throughout Germany and the world were reviewed.

Results: In 2007, in the first patient, the new technique was developed intraoperatively by necessity. Due to the convincing outcome, it was deliberately applied again several months later in another patient, and thereafter (sparsely) used for liver resection for various indications. Following oral communication, the method spread throughout Germany, and later - mainly following the publication of the initial multicentric German series - very quickly disseminated worldwide. Currently, it is used for a very (if not overly) broad spectrum of indications by many hepatobiliary surgery centers.

Conclusion: In-situ split/ALPPS is a newly developed technique for liver resection, which was established for very specific situations. This method has created a hype, and is currently used rather generously by many centers worldwide.

Keywords: ALPPS; In-situ split; Indication; Liver resection; Technique.

Fig. 1

First patient (hilar cholangiocarcinoma, Klatskin tumor) in whom an ‘!’ liver resection/ALPPS was performed in September 2007. a Contrast-enhanced computed tomography (CT) scan prior to the first surgery: dilated bile ducts, particularly in the left lateral section of the liver, in spite of preoperative drainage by endostent + percutaneous transhepatic cholangiography drainage (PTCD). b Contrast-enhanced CT scan 8 days after the first surgery with marked volume increase in the left lateral section. c Contrast-enhanced CT scan 7 day after the second surgery showing marked size increase of the remaining left lateral section.

Fig. 2

Second patient undergoing ‘!’ liver resection/ALPPS in 2008, with rectal cancer and synchronous colorectal liver metastases. Contrast-enhanced computed tomography scan 8 days after the first surgery.

Fig. 3

Patient with intrahepatic cholangiocellular carcinoma (iCCC), after prior portal vein embolization (PVE), undergoing ‘!’ liver resection/ALPPS in 2009. a Contrast-enhanced computed tomography (CT) scan prior to the first surgery, post PVE; body weight 78 kg; left lateral section of the liver: 190 ml (0.24% of body weight). b Contrast-enhanced CT scan prior to first surgery, post PVE; embolization material in the right liver. c Contrast-enhanced CT scan prior to the second surgery after 9 days; body weight 78 kg; left lateral section: 275 ml (0.35% of body weight).

Fig. 4

Patient not suitable for ‘!’ 2-stage hepatectomy (TSH), with synchronous colorectal liver metastases after neoadjuvant/conversion chemotherapy. a Contrast-enhanced computed tomography (CT) scan showing bilateral large colorectal liver metastases prior to chemotherapy. b Contrast-enhanced CT scan after 4 months of chemotherapy showing excellent response of the liver metastases, prior to the first surgery. c Intraoperative view at the end of the first surgery after resection of 5 metastases from the left (including segment IV) and the right portal vein division, in preparation for later removal of metastases on the right side by right hepatectomy. Preoperatively, ‘!’ liver resection/ALPPS had been planned; due to a larger than expected number of metastases in the left lobe (detected by intraoperative contrast-enhanced ultrasound), the strategy was changed intraoperatively. d Contrast-enhanced CT scan 8 weeks after primary surgery showing increase in volume of the left liver (including segments IV and I), prior to the second surgery following TSH/portal vein ligation. e Contrast-enhanced CT scan 5 weeks after the second surgery (right hepatectomy with minor parts of segment IVa).