Segment 4: a Key Point of ALPPS Procedure

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To the Editor:
We read with interest the work of Clavien et al,1 “Is partial-ALPPS safer than ALPPS? A aingle-center experience.” The authors conclude that when compared with patients who underwent complete partition, those who underwent 50% to 80% partition displayed similar liver hypertrophy kinetics that allowed for completion of the second stage, fewer severe complications after stage one procedure, and reduced operative mortality. They speculate that the partial liver partition approach—that is, associating liver partition and portal vein ligation for staged hepatectomy (p-ALPPS)—is a safer operation than traditional ALPPS.
The initial enthusiasm, generated by the work of Schnitzbauer et al2 was followed by a general skepticism for the highy morbidity rates ranging from 59% to 64% and a higher inhospital mortality rates of 12 to 16% in comparison with data reported in the literature for major liver resections. ALPPS procedure is an important surgical option to overcome the main limitations of the two-step classic strategy, but not executable in all cases for technical reasons when the tumor invades the right portal vein, (i) in case of high risk of tumor progression between the two steps and (ii) in case the FLR may not be hypertrophied enough for major resections.3
Complete tumor resection in the liver is the only chance to obtain long-term survival in patients with hepatic tumor or metastasis from other primary cancers. Staged hepatectomies in which the surgeon perform partial resection in one side of the liver and after 4 to 6 weeks proceed with the resection of the other side are standardized procedures for years. The main drawback is the risk of cancer progression when waiting for the second-stage hepatectomy.4
The recent meta-analysis of Kokudo et al5 shows that about 3 years after the inaugural publication of the novel ALPPS technique, the level of evidence supporting its advantages compared with traditional two-stage (TSH) strategy remains low and there wasn’t any statistical difference between the two types of surgeries in regeneration volume, but the kinetics growth of the future liver remnant (FLR) after ALPPS is very impressive respect TSH.
According to our experience, p-ALPPS is an attractive technical simplification and can extend the indications of ALPPS procedure. We performed six p-ALPPS in our center and the indications for the procedures were hepatocellular carcinoma in cirrhotic patients (n = 5) and colorectal liver metastases (n = 1). Liver transection involved at least 50% of the future transection plane. We observed a rapid hypertrophy in p-ALPPS within a median time of 7 days. All patients underwent a fast completion of the two-stage hepatectomy. No severe postoperative complications were observed after stage one procedure. In one case, we performed during the second stage vascular resection of the middle hepatic vein with reconstruction using a cold-stored vein allograft. The patient had bilobar colorectal hepatic metastases and R0 resection required right hepatectomy, partial resection of segment III and segment IV with resection of middle hepatic vein for incasement. CT volumetry revealed a very small left lobe of the liver. The projected FLR volume was 296 mL, 26% of total liver volume and body weight ratio was 0.6.
We therefore decided to adopt the p-ALPPS approach. During the first stage, the tumor in segment III was enucleated, and the liver parenchyma was partitioned for above 50% of total along the Rex-Cantlie line so that all other tumors were on the resected side except one metastases involving the middle hepatic vein in segment IV. During the second stage, we completed the parenchymal transection and we resected the tumor in segment IV en bloc with the middle hepatic vein for a length of 6 centimeters.
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