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Clinical manifestationsPeripheral Arterial Disease (PAD) manifests through a range of symptoms, from the characteristic intermittent claudication to atypical presentations and severe complications in advanced stages. Intermittent claudication, a hallmark symptom of PAD, presents as exercise-induced muscle pain that typically resolves within minutes of rest. This pain is reproducible and stems from inadequate blood flow, leading to the accumulation of lactic acid produced during anaerobic...
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Related Experiment Video

Updated: May 4, 2026

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Defining indications to ALPPS procedure: technical aspects and open issues.

Francesca Ratti1, Federica Cipriani, Annalisa Gagliano

  • 1General Surgery Department, Hepatobiliary Surgery Unit, IRCCS H San Raffaele, Via Olgettina 60, 20132, Milan, Italy, ratti.francesca@hsr.it.

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The associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS) technique rapidly increases future liver remnant (FLR) for liver surgery. However, complications arose in some patients, necessitating a re-evaluation of its indications.

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Area of Science:

  • Hepatobiliary Surgery
  • Surgical Oncology
  • Liver Transplantation

Background:

  • Surgical treatment of hepatic tumors is limited by future liver remnant (FLR) size, impacting postoperative liver failure risk.
  • Associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-stage technique to rapidly increase FLR.
  • Current indications for ALPPS are not clearly defined.

Purpose of the Study:

  • To evaluate the intraoperative and postoperative outcomes of the ALPPS procedure.
  • To define and re-evaluate the indications for ALPPS in patients with hepatic tumors.

Main Methods:

  • A series of eight patients undergoing ALPPS between January and December 2012 were analyzed.
  • Patients were divided into two series: Series 1 (right trisectionectomy for biliary confluence tumors) and Series 2 (right hepatectomy for colorectal liver metastases).
  • Intraoperative findings and postoperative outcomes were assessed.

Main Results:

  • All patients achieved an adequate FLR within a median of 7.5 days, with a 100% program completion rate.
  • Series 1 patients experienced complications including bile leakage and sepsis, with one mortality due to multi-organ failure.
  • Series 2 patients had an uneventful postoperative course, with no disease progression or liver failure.

Conclusions:

  • The ALPPS approach can rapidly increase FLR, but carries risks of complications, particularly in patients with biliary confluence tumors.
  • Initial indications for ALPPS in Klatskin tumors require re-evaluation due to observed complications.
  • ALPPS is currently best indicated for a subset of patients with colorectal liver metastases.