Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS)
CASE SCENARIO 1
Mr W, a 59-year-old gentleman presented with rectal bleeding and weight loss. CT scan results showed concentric mural thickening of the rectosigmoid colon and bilobar liver metastases. Colonoscopy findings showed a stenotic tumour at 20cm and was unable to negotiate through. He had insufficient remnant liver volume to survive a one-stage operation to remove all his liver metastases. Various treatment options were discussed with the patient including: downstaging chemotherapy, colonic resection followed by Portal Vein Embolisation (PVE) and liver resection, and Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure with extended right hepatectomy and synchronous resection of the rectosigmoid tumour.
He opted for the ALPPS procedure with extended right hepatectomy and synchronous resection of the rectosigmoid tumour, which was performed successfully. He made good recovery with no complications, and was discharged 19 days following his two-stage operation with curative intent. He is now receiving his adjuvant chemotherapy and has no recurrance on his recent CT scan 6 months from his operation.
CASE SCENARIO 2
Mr K, a 47-year-old gentleman presented with rectal bleeding and altered bowel habit. Colonoscopy findings showed a tight stenotic circumferential rectal tumour. CT scan results showed a locally advanced rectal cancer with extensive bilobar liver metastases involving every segment of his liver. After a defunctioning ileostomy, he underwent six cycles of neoadjuvant chemotherapy and targeted therapy to downstage his disease. Both the rectal tumour and his liver metastases reduced considerably in size after neoadjuvant therapy. An ALPPS procedure was performed with multiple wedge resections of the left lobe liver and synchronous low anterior resection in the first stage, followed by extended right hepatectomy in the second stage. Apart from a right pleural effusion, wound infection and urinary retention, he made a good recovery, and was discharged 16 days following his two-stage operation. He is currently receiving his adjuvant chemotherapy.
Since June 2015, Dr Low Jee Keem, Consultant of the Hepato-Pancreato-Biliary Surgery Service in Tan Tock Seng Hospital (TTSH), and Dr Tay Guan Sze, Head and Senior Consultant of the Colorectal Surgery Service of TTSH, have been performing the ALPPS procedure and synchronous colorectal surgery. The two scenarios mentioned illustrate how ALPPS helps with the treatment of patients with colorectal liver metastases. ALPPS can also be performed for other primary liver tumours such as hepatocellular carcinoma and neuroendocrine tumours.
Professor Schlitt first performed ALPPS in 2007 at Ragensburg, Germany and the technique was first presented to a German congress in 20101. It is a modification of two-stage hepatectomy that enables liver surgeons to resect advanced liver tumours in a short time interval. In the history of liver surgery, this represents a real breakthrough in the approach to treat advanced liver tumours.
ALPPS permits surgeons to remove a large part of the liver in two steps. In the first stage of the operation, the liver parenchyma is transected along the intended line of resection and the future liver remnant is cleaned of any tumour, as in the case of bilobar tumours. The portal vein of the liver lobe that will be removed is ligated. The patient is then allowed to recover for one to two weeks.
During this time, there will be rapid growth of the future liver remnant. After one to two weeks, the second stage of the operation is performed where the portal vein ligated lobe is removed and the patient is rendered tumour free.
This surgical strategy has several advantages:
- It induces rapid growth or liver hypertrophy that is unparalleled by other methods such as the traditional portal vein embolisation. It has been shown consistently that the future liver remnant volume will hypertrophy by 61-93% over a median of 9-14 days2.
- It helps to prevent post operative liver failure; the diseased lobe of the liver acts as an auxiliary liver whilst waiting for the future liver remnant to grow during the first and second week.
- In cases of metastatic disease, for which combined surgical procedure may require a greater functional liver reserve, this new strategy enables the synchronous resection of the primary tumour and aggressive removal tumour in the future liver remnant.
- It significantly reduces the time from surgery to chemotherapy as compared to the traditional treatment: meaning early definitive liver resection, unlikely tumour progression and faster recovery for the patient with early restart of chemotherapy. For traditional colorectal surgery, chemotherapy, sequential PVE and liver resection usually followed. There is a failure rate of 20-40% in PVE where tumours may progress during the period of post PVE, whilst waiting for the liver to hypertrophy and liver surgery to be performed.
The main controversial issue is that this new surgery comes with a price. There is still a high morbidity and mortality associated with this procedure; 6-12% mortality and 53-68% morbidity3. However, it varies from centre to centre and is only performed at certain hospitals in the world.
It would certainly benefit some patients, especially the young/middle-aged patients who have extensive (bilobar) liver tumours or have insufficient liver remnants if their advanced/extensive liver tumours were to be removed. ALPPS offers a chance of cure to these patients that other modalities of treatment cannot.
Schnitzbauer A, Lang S A, Fichtner-Feigl S, Loss M, Kroemer A, Goessmann H, Farkas SA, Kirchner G, Jung EM, Scherer MN, et al. In situ split with portal vein ligation induces rapid left lateral lobe hypertrophy enabling two-staged extended right hepatic resection. Berlin: Oral Presentation; 2010. p. 35
Bertens KA, Hawel J, Lung K, Buac S, Pineda-Solis K, Hernandez-Alejandro R. ALPPS: challenging the concept of unresectability – a systematic review. Int J Surg. 2015 Jan;13:280-7
Alvarez FA, Ardiles V, de Santibañes M, Pekolj J, de Santibañes E. Associating liver partition and portal vein ligation for staged hepatectomy offers high oncological feasibility with adequate patient safety: a prospective study at a single center. Ann Surg. 2015 Apr;261(4):723-32