Is the ALPPS procedure effective in patients with fibrosis?

The “Associating Liver Partition with Portal vein ligation for Staged hepatectomy” (ALPPS) procedure has recently been successfully introduced for patients with advanced liver tumors [1]. However, the procedure remains controversial due to high morbidity and mortality rates. Accumulating evidence suggests that the ALPPS procedure should be limited to patients with colorectal liver metastases,. However marginally resectable HCC is are a common problem for liver surgeons . A recent analysis of the ALPPS registry found HCC in 17 patients had perioperative mortality after ALPPS of 12% and a Clavien-Dindo complication rate of > IIIb in 25% of patients. Our hypothesis is that the ALPPS procedure may be unsuitable for patients with HCC due to the underlying liver disease Published data on patients with HCC and underlying liver disease undergoing ALPPS is very limited. So far, only one case series consisting of only 3 HCC cases has been published [2]. Liver fibrosis has previously been shown to substantially reduce hypertrophy response (up to 50%) upon portal vein embolization in portal vein embolization[3]. Underlying liver disease might be the reason why ALPPS seems less safe and effective in HCC .