Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS)

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 2010. 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:

1. 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 days.

2. 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.

3. 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.

4. 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.