LETTER TO THE EDITOR Simplifying the ALPPS Procedure by the Anterior Approach To the Editor: e read with great interest the article by Schnitzbauer et al1 in March 2012 on the excellent outcomes of right portal vein ligation and in-situ split for induction of rapid future liver remnant hypertrophy, a novel procedure that was later termed as “Associating Liver Partition and Portal vein ligation for Staged hepatectomy” (ALPPS).2 Since then, we have had the opportunity to perform ALPPS in 2 of our patients: a 6-year-old girl with hepatoblastoma and a 62-year-old man with hepatitis B–related hepatocellular carcinoma. One major concern about ALPPS was the deployment of a plastic bag to wrap around the right liver to prevent adhesion formation and to contain possible bile leak.3 However, a potential pitfall will be precipitation of intraabdominal infection in the presence of foreign body and the necessity for a second laparotomy to remove the bag even if hypertrophy fails to occur. To address this issue, we have adopted the “anterior approach” for the insitu split procedure, based on our experience on the same technique for resections of large liver tumors.4 Of particular interest was the second patient with a right-lobe hepatocellular carcinoma measuring 10 cm in diameter and Child A cirrhosis. Preoperative indocyanine green clearance rate was 17.8% at 15 minutes, and the left liver volumetry was 286.2 mL, that is, 26.6% of the estimated total liver volume. Parenchymal split was performed by CUSA after right portal vein ligation. Intraparenchymal bile ducts were exposed and divided individually between clips or ligatures. The right portal pedicle was encircled intraparenchymally and retracted caudally to facilitate further parenchymal split cranially and toward the inferior vena cava. The entire course of middle hepatic vein was exposed after the split and was divided at its origin. No Pringle maneuver was used. The
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right liver was not mobilized during the first operation. A bile leakage test by injection of methylene blue dye into the cystic duct was performed. No drain was placed. The left liver remnant volume was increased by 26% to 360 mL on the seventh postoperative day, which corresponded to 33.5% of estimated total liver volume. In the second operation on the 10th postoperative day, only a few flimsy adhesion bands were encountered inside the peritoneal cavity. There was no evidence of bile leak from the raw surface. An extended right hepatectomy was readily completed after division of the right hepatic artery, right hepatic duct, and right hepatic vein. Only at this point, the right liver was mobilized and removed from the retroperitoneal area. Liver remnant biopsy confirmed chronic active hepatitis with stage 2 liver fibrosis (Batts and Ludwig grading). Immunohistochemical staining showed a significant increment in the proportion of positively stained cells for Ki-67 and VEGF in the left liver remnant from 1% to 20% and from 10% to 100%, respectively. Our initial experience indicated that ALPPS was feasible in a patient with chronic liver disease. However, intra-abdominal placement of plastic bag remains the cause for concern to some surgeons.3,5 The anterior approach offers a solution by allowing a complete parenchymal split down to the inferior vena cava without prior mobilization of the right liver. As such, the amount of adhesions in the perihepatic and paracaval area is expected to be much less. Furthermore, it avoids iatrogenic tumor rupture during right liver mobilization, a surgical mishap that would otherwise increase the difficulties for the second operation. Besides, judicious use of CUSA facilitates exposure and meticulous control before division of intraparenchymal bile ducts. Together with the use of methylene blue test, all these measures would minimize the chance of bile leakage and further negate the use of plastic bag. As a result, the time pressure on the surgeon to perform the second operation is much relieved. At present, there is scanty data on the cellular mechanisms that account for the rapid
liver hypertrophy in ALPPS. Nonetheless, our preliminary findings corroborated with that of the Schnitzbauer study in which an upregulated cellular response in the form of proliferation and growth factor production was observed. Given the growing interest on this novel procedure in the surgical community, it is anticipated that more data will soon become available on this issue. As with any new surgical innovation, there is always a quest for further improvement. We believe that ALPPS could be simplified by the anterior approach and should be considered in the hands of experienced liver surgeons. Albert C. Y. Chan, MBBS(Lond) FRCS(Edin) Robert Pang, PhD Ronnie T. P. Poon, FRCS(Edin), PhD Division of Hepatobiliary and Pancreatic Surgery, and Liver Transplantation Department of Surgery Queen Mary Hospital The University of Hong Kong Hong Kong E-mail: [email protected]
REFERENCES 1. Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg. 2012;255:405–414. 2. de Santibanes E, Clavien PA. Playing Play-Doh to prevent postoperative liver failure: the “ALPPS” approach. Ann Surg. 2012;255:415–417. 3. Machado MA, Makdissi FF, Surjan RC. Totally laparoscopic ALPPS is feasible and may be worthwhile. Ann Surg. 2012;256:e13; author reply e16– e19. 4. Liu CL, Fan ST, Cheung ST, et al. Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study. Ann Surg. 2006;244:194–203. 5. Narita M, Oussoultzoglou E, Ikai I, et al. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg. 2012;256:e7–e8; author reply e16–e17.
Disclosure: The authors declare no conflicts of interest. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-e0003 DOI: 10.1097/SLA.0000000000000736
Annals of Surgery r Volume 260, Number 2, August 2014
www.annalsofsurgery.com | e3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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right liver was not mobilized during the first operation. A bile leakage test by injection of methylene blue dye into the cystic duct was performed. No drain was placed. The left liver remnant volume was increased by 26% to 360 mL on the seventh postoperative day, which corresponded to 33.5% of estimated total liver volume. In the second operation on the 10th postoperative day, only a few flimsy adhesion bands were encountered inside the peritoneal cavity. There was no evidence of bile leak from the raw surface. An extended right hepatectomy was readily completed after division of the right hepatic artery, right hepatic duct, and right hepatic vein. Only at this point, the right liver was mobilized and removed from the retroperitoneal area. Liver remnant biopsy confirmed chronic active hepatitis with stage 2 liver fibrosis (Batts and Ludwig grading). Immunohistochemical staining showed a significant increment in the proportion of positively stained cells for Ki-67 and VEGF in the left liver remnant from 1% to 20% and from 10% to 100%, respectively. Our initial experience indicated that ALPPS was feasible in a patient with chronic liver disease. However, intra-abdominal placement of plastic bag remains the cause for concern to some surgeons.3,5 The anterior approach offers a solution by allowing a complete parenchymal split down to the inferior vena cava without prior mobilization of the right liver. As such, the amount of adhesions in the perihepatic and paracaval area is expected to be much less. Furthermore, it avoids iatrogenic tumor rupture during right liver mobilization, a surgical mishap that would otherwise increase the difficulties for the second operation. Besides, judicious use of CUSA facilitates exposure and meticulous control before division of intraparenchymal bile ducts. Together with the use of methylene blue test, all these measures would minimize the chance of bile leakage and further negate the use of plastic bag. As a result, the time pressure on the surgeon to perform the second operation is much relieved. At present, there is scanty data on the cellular mechanisms that account for the rapid
liver hypertrophy in ALPPS. Nonetheless, our preliminary findings corroborated with that of the Schnitzbauer study in which an upregulated cellular response in the form of proliferation and growth factor production was observed. Given the growing interest on this novel procedure in the surgical community, it is anticipated that more data will soon become available on this issue. As with any new surgical innovation, there is always a quest for further improvement. We believe that ALPPS could be simplified by the anterior approach and should be considered in the hands of experienced liver surgeons. Albert C. Y. Chan, MBBS(Lond) FRCS(Edin) Robert Pang, PhD Ronnie T. P. Poon, FRCS(Edin), PhD Division of Hepatobiliary and Pancreatic Surgery, and Liver Transplantation Department of Surgery Queen Mary Hospital The University of Hong Kong Hong Kong E-mail: [email protected]
REFERENCES 1. Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg. 2012;255:405–414. 2. de Santibanes E, Clavien PA. Playing Play-Doh to prevent postoperative liver failure: the “ALPPS” approach. Ann Surg. 2012;255:415–417. 3. Machado MA, Makdissi FF, Surjan RC. Totally laparoscopic ALPPS is feasible and may be worthwhile. Ann Surg. 2012;256:e13; author reply e16– e19. 4. Liu CL, Fan ST, Cheung ST, et al. Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study. Ann Surg. 2006;244:194–203. 5. Narita M, Oussoultzoglou E, Ikai I, et al. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg. 2012;256:e7–e8; author reply e16–e17.
Disclosure: The authors declare no conflicts of interest. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-e0003 DOI: 10.1097/SLA.0000000000000736
Annals of Surgery r Volume 260, Number 2, August 2014
www.annalsofsurgery.com | e3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
