ALPPS for cirrhotic liver

Abstract

<p>Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has been regarded as one of the most novel procedures for flow modulation in future liver remnant in recent years. The initial results for ALPPS procedure were criticized for its rather high incidence of postoperative morbidity and mortality. To address this issue, anterior approach with meticulous parenchymal dissection was first adopted in our center and the practice to use a plastic bag to wrap around the tumor-bearing liver lobe was abandoned. With cumulative experience, the postoperative outcomes for ALPPS have dramatically improved with a postoperative liver failure rate after stage 2 as below 5% and a 30-day mortality rate benchmarked as below 4%. Furthermore, the application for ALPPS has expanded to include chronic hepatitis or cirrhosis-related hepatocellular carcinoma in view of its prevalence in Asia, despite the initial skepticism about its effect on liver hypertrophy in diseased liver. Nonetheless, with meticulous surgical techniques and postoperative management, we have demonstrated that ALPPS could also be effective in chronic hepatitis, or even cirrhosis with satisfactory oncological outcomes. Furthermore, a complete split could induce a much greater rate of future liver remnant hypertrophy than partial split without compromising the safety profile of the procedure. As we become more accustomed to the ALPPS techniques and gain more understanding about the degree of split in relation to the amount of liver hypertrophy, the future development would inevitably be the shift from an open to a minimally invasive approach, at least for stage 1 procedure. It is therefore in the best interest for future generations of liver surgeons to become technically familiar with both the ALPPS procedure and advanced laparoscopic liver surgery.<br></p>