Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned?

Abstract

In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of twostage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.

Keywords: ALPPS; ALPPS registry; Carcinoma; Perihilar cholangiocarcinoma; Two-stage hepatectomy; hepatocellular.

Fig. 1

Classic ALPPS (complete parenchymal transection and ligation of the right portal vein) for colorectal liver metastases. (A, B) CT scan at the time of diagnosis; FLR encircled (red). (C, D) CT scan after 12 cycles of chemotherapy and targeted therapy (folfiri+bevacizumab) (*cyst); FLR volume=186 mL. (E) CT scan 8 days after step 1 (complete parenchymal transection and ligation of the right portal vein plus wedge resection of Seg II/III); FLR with 98% increase in volume (186 to 369 mL). (F) Resection specimen (R0-resection). ALPPS, associating liver partition and portal vein ligation for staged hepatectomy; CT, computed tomography; FLR, future liver remnant.

Fig. 2

Timeline of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and its most important variations. Hybrid ALPPS, ALPPS with portal vein embolization instead of portal vein ligation; MWA, microwave ablation; RFA, radiofrequency ablation; Mini ALPPS, partial ALPPS plus simultaneous portal vein embolization; TIPE ALPPS, ALPPS with transileocolic portal vein embolization. *In 2007, the first in-situ split was performed; the first publication (classic ALPPS) was in 2012.

Fig. 3

Indications for ALPPS, data from the registry (May 2019; https://ALPPS.net). ALPPS, associating liver partition and portal vein ligation for staged hepatectomy; CRLM, colorectal liver metastases; ICC, intrahepatic cholangiocarcinoma; PHC, perihilar cholangiocarcinoma; LM, liver metastases; HCC, hepatocellular carcinoma.