Taking “Play-Doh” to the Kids: Using the ALPPS Approach to Prevent Postoperative Liver Failure

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In this edition of Annals of Surgery, Johnny Hong et al1 publish their article “Modified associating liver partition and portal vein ligation for staged hepatectctomy for hepatoblastoma in a small infant: how far can we push the envelope?” This group have recognized the importance of what has become known as “ALPPS” for adults where the burden of malignant liver disease is too great for single stage surgery and where classical 2 stage surgery is unlikely to be successful because of progression between the stages. This surgery appears to have been carried out in the youngest patient (54 days) ever described so this success is significant.
Classically, hepatoblastoma is treated by resection or if unresectable then by neoadjuvant chemotherapy and liver resection or transplantation. However, as the authors suggest, resection is preferable to a liver transplant because of the higher recurrence rate and the need for long-term immunosuppression with transplantation. When the only limiting factor for resection is future liver remnant (FLR) size, the concept is using the ALPPS approach for small children is attractive as it allows a more rapid progression to potentially curative surgical resection and, if we are to extrapolate from adult data, a higher chance of completion of both stages than can be achieved with classical 2 stage liver surgery.
The acronym “ALPPS” was coined by Eduardo de Santibanes and Pierre-Alain Clavien in 2012 to describe surgery that involved “Associating Liver Partition and Portal vein ligation for Staged hepatectomy” following on from the initial reports over the previous 2 years from both Germany and Argentina.2–4 Early reports suggested there was a very high risk of perioperative mortality but at the same time ALPPS appeared to offer hope for patients with a high burden of disease. As a result, there were both strong proponents and opponents for this innovative procedure at an early stage and much argument remains today.5
The critical question in radical liver resection surgery relates to the size and function of the future liver remnant and the experience of the operating team is crucial for success. Liver regeneration is not only governed by adequate portal vein and hepatic arterial inflow but also by the adequacy of hepatic venous outflow. This is compounded by factors such as age and the impact of chemotherapy and underlying parenchymal liver disease. Literature relating to children is scarce so this article is important for that reason alone.
In this case, Hong et al1 chose to modify the ALPPS procedure to reduce the chance of postoperative liver failure at stage one by carrying out an 80% parenchymal transaction with hepatic vein preservation. This more partial hepatic transaction at stage one was highlighted by Clavien's group in 2015 as “partial ALPPS” (or p-ALPPS) and described as a 50% to 80% transaction associated with a reduction in mortality from 22% down to zero so this was a significant observation.6 Importantly, FLR hypertrophy does not appear to be compromised by this technique. Others have described this approach as a “mini-ALPPS” and the aim has been to limit morbidity between the 2 stages. It therefore seems sensible to employ this modification for such a young patient.
There is no doubt that these complex procedures must only be undertaken by experienced surgeons in high-volume centers, and patient selection should be by means of a multidisciplinary team effort. The careful management of these patients during the postoperative course of both surgical procedures is crucial. I congratulate the authors on their meticulous attention to detail that has no doubt enabled success.

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