ALPPS - When to Perform Second Stage?

Surgical resection is the only curative modality of treatment in patients with colorectal liver metastases. Although multiple and bilobar metastases are correlated with worst prognosis, this condition should not be considered a contraindication to hepatic resection, because even in this situation, surgery is still the only curative treatment . The most common strategy for these patients is to perform neoadjuvant therapy followed by two-stage hepatectomy with minor resections on the left lateral liver (future liver remnant - FLR) combined with right portal vein occlusion as the first stage, followed by right trisectionectomy. However, insufficient FLR volume may preclude liver resection even after portal vein occlusion. To overcome this problem, a new method to increase liver hypertrophy prior extended hepatectomy was described, ALPPS for Associating Liver Partition and Portal vein ligation for Staged hepatectomy. This technique has been claimed to produce a marked hypetrophy of future liver remnant (FLR) in a shorter period of time compared to the traditional two stage hepatectomy. In the early experience a higher morbidity and mortality had been observed. After careful examination of the cases, some immediate reasons for these results were identified. ALPPS performed in older patients, with additional pancreatic resection, in patients with hilar cholangiocarcinoma did worse than other patients. Now we can perform a safer ALPPS. However, there still debate among some authors if 7-9 days is enough to produce adequate liver regeneration. In patients with FLR not so small, this time may be enough but in extremely small ALPPS we may experience liver failure.