Two-Stage Hepatectomy and ALPPS

Indications and patient selection: 1) Two-stage hepatectomy indications - colorectal liver metastases (most common indication, often bilobar with multiple lesions), hepatocellular carcinoma in cirrhotic liver, intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma (Klatskin tumor), large hepatic adenoma, gallbladder cancer with extensive liver involvement, central tumors requiring extended hepatectomy with insufficient FLR; 2) ALPPS indications - similar to TSH but particularly when rapid progression risk (rapidly progressive metastases failing chemotherapy), patient comorbidities or coagulopathy preclude safe PVE, failed PVE with inadequate hypertrophy, urgent oncologic timeline; 3) FLR assessment - volumetric CT or MRI; FLR <25-30% in healthy liver, <30-40% in cirrhosis, <30-40% post-chemotherapy associated with high risk of post-hepatectomy liver failure (PHLF); 4) Patient evaluation - performance status (ECOG 0-1 typically), comorbidities (cardiac, pulmonary, renal), liver function (Child-Pugh A or B7, indocyanine green retention test ICG-R15 <15%, MELD <10), nutritional status, oncologic staging (cross-sectional, FDG-PET); 5) Multidisciplinary tumor board - essential for decision-making between TSH, ALPPS, conventional hepatectomy, conversion chemotherapy, palliative care; 6) Contraindications - extrahepatic metastases (relative; oligometastatic disease may proceed), severe comorbidities, decompensated cirrhosis, performance status >2, refusal of major surgery; 7) Modern selection - growing experience suggests careful patient selection (performance status, age <70-75, FLR characteristics) is critical; high-risk ALPPS patients may benefit from TSH instead.

Two-stage hepatectomy technique: 1) Stage 1 - portal vein embolization (PVE) more commonly than ligation; performed by interventional radiology, transhepatic puncture into right portal vein contralateral to FLR; embolic agents (cyanoacrylate glue, microparticles, ethanol, ethanol-iodized oil); 2) Hypertrophy interval - 4-8 weeks after PVE; serial volumetry at 3-4 weeks; expected hypertrophy 30-50% in normal liver, 25-40% in chronic liver disease; 3) Stage 2 - definitive hepatectomy 4-8 weeks after PVE if hypertrophy adequate; FLR >25% normal liver, >30-40% chronic liver disease for safe resection; usually right or extended right hepatectomy, occasionally left or trisectionectomy; 4) Failure of TSH - inadequate hypertrophy in 10-25%; tumor progression in 20-30% (especially in colorectal mets); abandoning hepatectomy 15-30% overall; 5) Salvage options for inadequate hypertrophy - additional embolization of right hepatic vein, ALPPS as rescue, conversion chemotherapy with reassessment; 6) Outcomes - feasibility of stage 2: 70-85%; mortality 3-5%; morbidity 25-35%; 5-year survival for CRLM 30-45%; 5-year HCC survival 35-50%.

ALPPS technique and outcomes: 1) Stage 1 - laparotomy with bilateral subcostal incision; complete mobilization; division of round and falciform ligaments; complete in-situ liver transection along anatomic plane (typically along portal fissure for right hepatectomy); preservation of structures to be retained; right portal vein ligation; right hepatic artery, bile duct, hepatic veins preserved; 2) Postoperative interval - 7-14 days (vs 4-8 weeks for TSH); volumetric CT day 7-10; expected hypertrophy 60-80% (>40% gain in FLR volume); 3) Stage 2 - completion hepatectomy with division of right hepatic artery, bile duct, and hepatic veins; reconstruction as needed (biliary anastomosis, hepatic vein, vena cava); 4) Variants - mini-ALPPS (partial transection 50-75%), ALPPS with Tourniquet (no transection, only hilar tourniquet), ALPPS with arterial occlusion, hybrid ALPPS combining radiologic and surgical approaches, RAPID-ALPPS, robotic ALPPS; 5) Outcomes vs TSH - feasibility of stage 2: 95-99% (vs 70-85% TSH); morbidity 40-60% (vs 25-35% TSH); 90-day mortality 5-15% (vs 3-5% TSH); high mortality particularly with bile duct injury, infection, sepsis, hepatocellular carcinoma in cirrhosis (avoid in this group); 6) Patient selection critical - meta-analyses suggest age <60, no cirrhosis, colorectal mets, performance status 0-1 are best candidates; HCC, PSC, perihilar cholangiocarcinoma poor candidates; 7) Long-term outcomes - 5-year survival CRLM 35-45%; comparable to TSH; recurrence-free survival 25-30%; 8) Complications specific to ALPPS - PHLF (post-hepatectomy liver failure) 5-15%, biliary complications 15-25%, infections 25-35%, ICU stay common, longer overall hospital stay; 9) ALPPS Registry data - international ALPPS Registry tracks outcomes; standardized definitions and reporting; 10) Future developments - precision medicine approach, biomarkers for hypertrophy prediction, personalized strategies, role of new conversion chemotherapy regimens, liquid biopsy monitoring.