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Inverting the ALPPS paradigm by minimizing first stage impact: the Mini-ALPPS technique
Eduardo de Santibañes1,2, Fernando A Alvarez3, Victoria Ardiles3
1Hepato-Pancreato-Biliary and Liver Transplant Sections, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina. eduardo.desantibanes@hospitalitaliano.org.ar.
This study introduces a modified approach to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), making the first stage less aggressive. This inverted strategy aims to improve patient recovery and safety in liver surgery.
Area of Science:
- Hepatobiliary Surgery
- Surgical Oncology
- Liver Transplantation
Background:
- The standard associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) involves an aggressive initial surgery, often leading to significant morbidity and mortality.
- A paradigm shift in surgical staging may enhance patient recovery and outcomes during the interval period.
Purpose of the Study:
- To propose and evaluate a novel technical paradigm for ALPPS by inverting the aggressiveness of surgical stages.
- To minimize the impact of the first surgical stage to promote faster patient recovery.
Main Methods:
- The modified ALPPS approach involves partial parenchymal transection and intraoperative portal vein embolization (PVE) in the first stage.
- Liver mobilization is minimized, and hilar dissection is avoided during the initial procedure.
- Completion surgery is performed after confirming adequate future liver remnant (FLR) hypertrophy and function.
Main Results:
- The technique was applied to four patients with liver tumors (1 hepatocellular carcinoma, 3 colorectal metastases).
- Mean FLR hypertrophy reached 62.6% (range 49-79%).
- All patients achieved R0 resection margins without developing liver failure or major complications.
Conclusions:
- The inverted ALPPS strategy, featuring a less aggressive first stage, proved feasible and safe.
- This approach combines partial parenchymal transection, intraoperative PVE, and oncological principles to facilitate tumor resection in selected patients with extensive liver disease.
- Minimizing the initial surgical burden enhances patient recovery and allows for a more comprehensive second-stage procedure.
